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NNW SAN JOAQUIN COUNTY v� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: S-EH LOG # <br /> (Circle One) f <br /> B. SOURCE OF INFORMATION <br /> Name: P�-,atn:t22 oti. Phone: <br /> Company: <br /> Address: -33 <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: -516 A dYl&,--- / <br /> (Best Physical Description) i r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> �/-q/.62 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ��a u �- �cz-.-� -- K �' o . �� <br /> Contact Person: r - Telephone: L l5 S ql--s 73 <br /> Physical Address: -7o,3 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: �e <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> At O . <br /> EH 22 013 Rev. 91) <br />