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SAN JOAQUIN COUNTY ', ) <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: IT II III <br /> (Circle One) PHS-EH LOG # ��'_ / 0, <br /> B. SOURCE OF INFORMATION <br /> Original Source: <br /> Telephone: / 7 <br /> Reporting Agency Name: c) )S- <br /> Agency Contact: <br /> Telephone: CLO <br /> Address: 4Z G// T' <br /> C• LOCATION AND DATE OF DISCHARGE <br /> Location: LI'/;�44 <br /> (Beat Physical Description) (City or County) <br /> Date of Discharge: j,f- <br /> Date Notified: _/– <br /> D. RESPONSIBLE PERSON/BUSINESS U Time: 3 •`�D� <br /> Name of Business _L„j—,j <br /> Contact Person: Z z <br /> Telephone: <br /> Physical Address: c-)v <br /> ,' O <br /> E. DESCRIPTION <br /> Type Release; l <br /> Volume; L4-s <br /> Chemicals: � <br /> F• ACTION TAKEN <br /> 7P <br /> .�i2o i Y5 s�7Un '' <br /> A1-7i74' �1 L,�s c� r <br /> EH 22 03 (Rev. 7/89) ' <br />