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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 INFORMATION <br /> lr� <br /> Name: L Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: one: �) <br /> Reporting Agency Name: <br /> Address: ---Iotl- E Q E>Lia2a <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: �:4 10f mo.i rJ c <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: W, oc+W\ <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ' <br /> F- + P -� <br /> � <br /> Contact Person: s-Ag � Telephone: L� <br /> Physical Address: �V1G 5. PA., s-� �--��r+-- <br /> Mailing Address: r', F"K fo4q :roe, co- 95--t0 8 <br /> E. DESCRIPTION <br /> Type of Discharge: Ute ca -NtVNMR-;-7�d <br /> Volume:,` <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN e L4 K) <br /> SITE STATUS r , .-\rLP A �a -. [t TZemh;,,3 t , F-„ �- 2- <br /> D Q,-4— <br /> :AAE r�� iU'� DF til <br /> EH 22 013 (Rev.4/91) <br />