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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> -� (Circle One) <br /> B. SOURCE OF I� C=RMT N , <br /> Name: / Phone: �) <br /> Company: <br /> Address: <br /> Designated Employee Name: hone: <br /> Reporting Agency Name: i - <br /> Address: <br /> C. LOCATION AND DATE OFDISCHAAGE _,,z ��� / <br /> Location: <br /> (Best Physical Descnp 'on) (City o ty Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BU ESS <br /> Name of Business: <br /> Contact Person: Tele ho "(_) <br /> >>_ >> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumst nces: <br /> F. ACTION TAKEN / <br /> i <br /> SITE,JDISPO ITIO <br /> EH 22 013 (Rev.4/91) <br />