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SAN JOAQUIN COUNTY <br /> NOTIFICAitON OF HAZARDOUS WASTE DISCriARGE <br /> HEALTH & SAFETY CODE 25180. 7 <br /> A. EMERGENCY LEVEL : V II III PHS-EH LOG # �- <br /> (Circle One) <br /> B . SOURCE OF INFO ATION / <br /> Name : � d n G -».p -� KeB�d /La�9 -A0. Phone : <br /> Company: a AZ CaP �532o dx , Toru ze �.� P <br /> Address : 171 n <br /> Designated Employee Name : Phone : ( ..) <br /> Reporting Agency Name : <br /> Address : <br /> Co LOCATION AND DATE OF DISCHARGE � <br /> Location: // . zc .LY /" /(U / ��d0 <br /> (Best Physical De cription) (City or Circle One <br /> Date of Discharge : _ �e� o urs <br /> Date Notified : /0 - 7- 1 / Time: /. 00 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business : PS _ <br /> Contact Person : iTelephone : (lop ) 5 / �2/dff� <br /> Physical Address : <br /> Mailing Address : / 9od W e4Vy eLZ <br /> E. DESCRIPTION <br /> Type of Discharge : _ � c <br /> Volume : <br /> Chemicals : <br /> Circumstances : Q�y <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91 ) <br />