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• SPN JOAQUIN COUN'T'Y • <br /> NC T IFT_C.QTICN OF F AZ.ARDOUS WASE' DISCHARGE <br /> H"c.4LTH & SAFEY CODE 25180.7 <br /> A E:�RGENCY LZVEL: I EI ® PHS-F-H LOG <br /> (Circle One) <br /> B. SOURCE OF INF RMAi7ON r <br /> Name: Phone: <br /> Company <br /> Address: ov 57YL' 67, Of <br /> Designated Employee Name: P one: C_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION DATE OF DISCHARGE <br /> Location: �dt c�i r �ti2 SAS '�00j Df �-fir/ Sri ' <br /> (B . hysicai escnvion) �— (City or Corny) Circle One <br /> Date of Discharge: io <br /> Date Notined: / / mow - Time' 2 <br /> D. RESPONSIBLE PERSON/B//US SS <br /> Name of Business: .d 'C�e <br /> Contact Person: � ephone: (�2 <br /> Physical Address: <br /> Mailing Address: <br /> DESC� ION <br /> T,-pe of Disc:'.arge: <br /> V oi=e: <br /> C`+ernicals: <br /> F. A N TAE—E-._ <br /> 2u,�o/ LOQ <br /> EH 22 013 (Rev.4/91) <br />