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SAN JOAQUIN COUNTY <br /> rr NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> t <br /> (Aa HEALTH & SAFETY CODE 25180.7 <br /> 0 <br /> A. EMERGENCY LEVEL('iII III PHS-EH LOG # <br /> (circle One) q 5 si ylu <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: C> '!-� <br /> Address: y `-IC ,41 <'�;; :� =f <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> ��ac-z/0/7 f�`ic�l�cl l 50 v <br /> (Best Physical Description) (City or-County)`Ckcle One <br /> Date of Discharge: -�o - `� <br /> Date Notified: Time: 7 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: .c_ - <br /> Contact Person: Snd /G N Telephone: ( /6 j <br /> Physical Address: foo.x�c.3 IJu -s <br /> Mailing Address: 3Z - <br /> E. DESCRIPTION <br /> Type of Discharge: elyl 5 f 4 7/ZO <br /> Volume: �- <br /> Chemicals: a .4,Ho i;,,Y, I u .0 ee7,'v <br /> Circumstances: r; - To/ 7.v/ s o�� a,`•c•�v ` 7 U�c <br /> ;.^� x 0 10, <br /> F. ACTION TAKEN_��ct�,�,��n �� rr c� ��i�lL�S</ S ✓://,� /�f.�s <br /> C^ �e <br /> s <br /> SITE DISPOSITION �/ — � � fit �o•'?P/<,,� �" <br /> EH 22 013 (Rev.4/91) <br />