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� � FILE copy <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION HAZARDOUS 25180.7 SCHARGE--- <br /> HEALTH SECODE <br /> A. EMERGENCY LEVEL' I II III <br /> PHS-EH LOG 9 O J Q 5 <br /> ircle one) <br /> B. } SOURCE OF INFORMATION <br /> Name: <br /> Phone:�05) <br /> Company: <br /> Address: Phone: <br /> Designated Employee Name: , <br /> Reporting gency Name: <br /> ' ifi�iN <br /> Address: 144. _f S <br /> C. LOCATION AND DATE OF DISCHARGE <br /> / D <br /> Location: �?�� �' (Cityor oun Circle one . <br /> (Best by ' Description) <br /> Date of Discharge/ Time: <br /> Date Notified: <br /> D. RESPONSIBLE PER�oSONIBUSINESS <br /> Name of Business: <br /> w Phone: <br /> Contact Person: <br /> Phvsical Address: A <br /> Mailing Address: <br /> E. DESCRIPTION I ' _ <br /> Type of Discharge: -Z - � <br /> Volume: <br /> Chemicals: amu / <br /> Circumstances: <br /> F. ACTION TAKEN <br /> i;�: f <br /> SITE DISPOSITION <br /> �a w! <br /> EH 22 013 (Rev. 08/20/98) <br />