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• SAN JOAQUIN COUNTY <br /> NOTIFIL,AON OF HAZARDOUS WASTE DI. LARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> D <br /> PHS-EH LOG <br /> A. EMERGENCY LEVELII III <br /> i(((I # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION Phone: LI <br /> Name: .a <br /> Company: <br /> -------------- <br /> Address• ' Phone: L� <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE / -_ <br /> Location: ` "� gity or County) Circle One <br /> (Best Physical Description) <br /> Date of Discharge: f - <br /> Time: <br /> Date Notified: <br /> -- <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Telephone: ? n <br /> Contact Person: < <br /> Physical Address: El ' <br /> Mailing Address: r <br /> E. DESCRIPTION <br /> Type of Discharge: /�1nrJ PC F. <br /> r. _ _ - �,� .1-✓-Y•t 1 �,Tri, .fir / <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION <br /> TAKEN <br /> -> <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />