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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:0 II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name:—H2 kiq,(,/ G z k Phone: <br /> Company: S AM C. <br /> Address: <br /> Designated Employee Name:_ Phone: (,Aj� (,�-3 � <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ;` Y7 ZL <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: GC n�.yy!�iG�Yt� <br /> Date Notified: -�� "� l Time: 'i-'0Q�2 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: v <br /> Contact Person: Telephone: �) <br /> Physical Address: ' r n c- 5--D0 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> c <br /> .iiCprnC�1/CT�. /_3_ 70 <br /> F. ACTI'CiN TAKEN <br /> SITE STATUS <br /> C�r L4M <br /> 0. 114- <br /> -H 22 013 (Rev.4/91) <br />