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V4 TT- 9-4-cs <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: i I III PHS-EH LOG #_ <br /> (Circle One) <br /> B. SOURCE OF INFORMATION Phone: L 407-96p <br /> Name:, �� s — <br /> Company: ��� ,, 2 2A! G�r,P Hca o <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Nam f S - 7b 9�� <br /> Address: /% • S� Q <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: �a ( Arl-c / or County) Circle One <br /> {Best Physical esc •p�o'n) � <br /> Date of Discharge. <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Telephone; 3 <br /> Contact Person: _ 15Z jDoy SAS �v �-{°7 7 ZeSo <br /> Physical Address: 2 3 G' E G <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: Cw <br /> Chemicals: v <br /> Circumstances: L w LcGi <br /> F. ACTION TAKEN G <br /> SITE DISPOSITION U w <br /> r <br /> f <br /> EH 22 013 (Rev-4/91) <br />