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SAN JOAQUIN (,OIJN'1Y <br /> NOTIFICATION OF- HAZARDOUS WASTE IJIISCHARG <br /> I TFALTI-I & SAFFTY CODE' 25180.7 <br /> A. EMFRGENGY LEVEL11 111 PIIS-ETI I.SX17 #_—{ J �'���' <br /> .1cude One) <br /> B. SOURCE OF INFORMA'T'ION <br /> Name: Phone: <br /> Comp ny-- <br /> Address: <br /> Designated Employee Name:__ Phone: <br /> Reporting Agency Naiiie:---.—.-.--,----.-, <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE 256)-Z)Z .07 <br /> Location: 1075 9(,l A" <br /> (Bestliysic.ql Description) Ci or Ifounty) Circle One <br /> 1)1.te of Discharge: _-4644-1c <br /> Date Notified: Time: /000— <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: � 6. <br /> Contact Person: /)Ult-k- Telephone: (L16 <br /> JPI- F6 e6 <br /> Physical Address: <br /> r - — <br /> Mailing Address: -5-16 <br /> G. DESCRIP'T'ION <br /> Type of Discharge: <br /> Voluine: <br /> Chetnic6ls: <br /> Circumstances: <br /> -,a :Z , a4yo-& <br /> F. ACTION TAKFN_O,_ <br /> 4J <br /> A/O <br /> SITEDISPOSITION -1b xqjo- 14-- y-6 <br /> 22 013 (Rev.1/91 ) <br />