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SAN JOAQUIN COUNTY 0 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: © II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: A& G e t ev�t�, , n'. C. s Phone: -57 013y <br /> Company: &K216=Y— co-Q <br /> Address: 3/76 QEvd. &le�-Q� Ca-P ?.5-6 F/ <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 1050 6. 6� <br /> (Best Physical Description) ' `or Cou ) Circle One <br /> Date of Discharge: -U1x4?- <br /> Date Notified: /- 4- 9'2- Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: mll�eK <br /> Contact Person: Telephone: lr/6 <br /> Physical Address: iso i Fle��•n - z��• �� d c. �� c r1 y s� <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: u�ur <br /> Chemicals: <br /> Circumstances: <br /> 9.r�lr eQ �touncdu/ dam �2 ls�u+�ea duzu�i �a�•-�c <br /> F. ACTION TAKEN <br /> o�te .ceG � �C 9c CdRccJQG.3. <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />