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J <br /> SAN JOAQUIN COUNTY ` <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE , q <br /> HEALTH & SAFETY CODE 25180.7 <,f <br /> A. EMERGENCY LEVEL: fi/ II 111 PHS EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INF RMATION �z Z3 �po7 <br /> Name: ��,'� K•� �'e� Phone: <br /> Company: <br /> Address: •d,Sc s'1 F.c,. f S2:3 n O ? <br /> Designated Employee Name: Phone: O <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE . <br /> Location: ? S-7 �.• /I7=' S--? / I/�-r-y ;. <br /> (Best Physical Description) qty or County) Circle One <br /> Date of Discharg�: v►- <br /> Date Notified: f'; '12 Time:. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: �f <br /> Contact Person: Trn�' ' - R- Telephone: Vit? ?� 7- L yo <br /> Physical Address: - <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: � �-- <br /> Chemicals: <br /> Circumstanc s: - <br /> �- <br /> F. ACTION <br /> TAKEN <br /> f � Y <br /> SITE STATUS 4! S r <br /> � r <br /> EH 22 013 (Rev-4/91) <br />