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YAN JOAQUIN COUNTY <br /> OUS WASTE DISCHARE <br /> NOTIFICATION OF HAZARD r <br /> . 1 <br /> HEALTH & SAFETY CODE 25180.7 l <br /> ff <br />` L <br /> PHS-EH LOG #,_ �=:1 4 � <br /> A. EMERGENCY LEVEL: <br /> (Circle One) <br /> SOURCE OF INFORMATION B. SO MATIO Phone: G� <br /> Name: <br /> L Company: <br /> Address: �, U cf Phone: <br /> Designated Employee Name: _ .. J J <br /> Reporting Agency Name: <br /> Address: <br /> LOCATION AND DATE OF DISCHARGE <br /> Location: u n (City or Cqurnty) Circle One <br /> (Best Physical Desc4pdon)� <br /> L Date of Discharge: M <br /> Time: <br /> Date Notified: Il' <br /> RESPONSIBLE PERSN/BUS[NSS _ P M �-��Name of of Business: Telph ne: <br /> LContact Person: <br /> Physical Address: 3c- <br /> LMailing Address: <br /> E. DESCRIPTION } <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: r <br /> Circumstances: A <br /> L <br /> F. ACTION TAKEN <br /> �. .�► -a <br /> � C <br /> T <br /> SITE D[SPQ <br /> SITION F <br /> L <br /> EH 22 013 (Rev.4/91) <br />