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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCGE <br /> HEALTH & SAFETY CODE 25180.7 ) <br /> ry <br /> A. EMERGENCY LEVEL: I 11C PHS-EH LOG # { (� <br /> (Circle One) <br /> B. SOURC OF INF RMATION <br /> Name: Phone: .BOSS <br /> Company: <br /> Address: 16154 Zr" ,- SY, <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: X00 f /l a_, 57tS4,7-. / <br /> (Best Physical Description) City or County) Circle One <br /> Date of Discharge: 641� <br /> Date Notified: /L - //- l'5 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: - Yo T <br /> Physical Address: <br /> Mailing Address: ?L3, �SLa <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> "S-J-671. Errs G2� � <br /> F. ACTION TAKEN - <br /> ' <br /> z � <br /> SITE STATUS cS GP <br /> L <br /> EH 22 013 (Rev.4/91) <br />