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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180. 7 <br /> A. EMERGENCY LEVEL: oI II III PHS-EH LOG # O S� � <br /> (Circle One) <br /> Be SOURCE OF INFORMATION <br /> Name : 'ri mL c I I Phone : C.) <br /> Company: 5 -}a c I(--I� , <br /> Address : <br /> Designated Employee Name: phone: (7d 1 ) !0 3 '7 - Fs /0 <br /> Reporting Agency Name : <br /> Address : <br /> co LOCATION AND DATE OF DISCHARGE <br /> Location : � 5 �7 S C z bk n +rw <br /> (Best Physical Descri tion}) &,r County) Circle One <br /> Date of Discharge : b �- <br /> Date Notified : 0 L4 Time: g ' on all- <br /> Do RESPONSIBLE PERSON/BUSINESS <br /> Name of Business : S I d ' S o h <br /> Contact Person: �n r v2Telephone : (� y 5 <br /> Physical Address : <br /> Mailing Address : Q0145 <br /> E . DESCRIPTION <br /> Type of Discharge . 5 Lk �1 <br /> Volume : <br /> Chemicals : re e 0 S6 < r ri <br /> Circumstances : <br /> rv-\ <br /> F. ACTION TAKEN <br /> SITE ISPPS [ON v r � a k V^ <br /> ll � <br /> P�✓� I 1 <br /> 1 t <br /> EH 22 013 (Rev.4/91 ) <br />