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( b <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL. <br /> I TI III PHS-EH LOG # <br /> e One <br /> C ) <br /> B. SOURCE OF INFORMATION <br /> O <br /> Name: V I AA �-,., Phone: <br /> Company: !Cr . <br /> Address: C Sa <br /> Designated Employee Name: Z:f, Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS' <br /> Name of Business: <br /> Contact Person: zita Telephone: <br /> Physical Address: 10 a CS ac. a S 4. -- <br /> Mailing Address: s <br /> E. DESCRIPTION <br /> Type of Discharge: &, Zgtu-! <br /> Volume: 7 0 r �w <br /> Chemicals: PUS <br /> Circumstances: ra u-w. <br /> F. ACTION TAKEN <br /> C 2, .1r2 �"�r►- _ 1--�-r�` c� , t <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />