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0 <br /> SAN JaAQUIN COUNTY 41 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARG� <br /> HEALTH & SAFETY CODE 25180.7 <br /> r . <br /> A. EMERGENCY LEVEL: I0II III PHS-EH LOG # / f �T <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: 3-Tr--G Telephone: ( ;�O j ) G3 <br /> 166 A04Y, <br /> Reporting Agency Name: <br /> Agency Contact: Telephone:rri�&yy l� Telephone: ( z�,,- ) � S- 3ql <br /> Address: s-r 4A- <br /> C. <br /> 4C. LOCATION AND DATE OF DISCHARGE <br /> Location: Z z- 1 .5r- <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: •tl-A ` <br /> Date Notified: Time: f°- 4'0 <br /> D, RESPONSIBLE PERSON/BUSINESS <br /> Name of Business ' t! 5 AvrN Cd��,v"�" <br /> Contact Person: pi ty 6eW614- Telephone: <br /> Physical Address: 272- "i3 4 5T '�` � 2— <br /> E. DESCRIPTION <br /> Type Release: id1�- ,QC�Sro 7�G <br /> Volume: - <br /> Chemicals: GiSvG i t\i r <br /> F. ACTION TAKEN <br /> 469A 52ZA-� T�N ew /tom c62,� <br /> G-V^ W'T r-D Q,,-7W uA <br /> A <br /> j <br /> SZ T T'f�l3 cvra--'Tr 460 <br /> EH 22 013 (Rev. 02/90) <br />