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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:C[jII III PHS EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: /'fit( , 00 C9-� Phone: (_) <br /> Company: <br /> Address: .5 <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCARGE <br /> Location: /!1.3 A 'F�/"�{l <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: — 27 Time• L C� ✓ry <br /> D. RESPONSIBLE PERSON BUSINESS J <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: / , aZU <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circu Lances: ' e--- <br /> - <br /> h <br /> ACITN TAKEN A-rft <br /> 7- <br /> 4,-5 # J <br /> SITE STATUS <br /> v - <br /> c� G� P o <br /> EH 22 013 (Rev.4/91) <br />