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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I I1 III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFO IO�I <br /> Name: S 6 v Phone: �) <br /> Company: o r� <br /> Address: <br /> Designated Employee Name: r oSS Phone: y 6,P- <br /> Reporting <br /> ,PReporting Agency Name: <br /> Address: . 0 9k <br /> C. LOCATION AND DATE OF DISCC GE <br /> Location: /3�o S r�ICLe � <br /> (Best Physical Descrition) Q!Ddor County) Circle One <br /> Date of Discharge: /D 3 9 <br /> Date Notified: 1,91331sl Time: S'l <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: o <br /> Contact Person: 1 rlw J 64/ Telephone: ( 33 V-SD 06 <br /> Physical Address: urz s <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN cI <br /> SITE STATUS r & <br /> EH 22 013 (Rev.4/91) <br />