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%Or-- <br /> SAN JOAQUIN COUNTY P'yN TIFICATION OF HAZARDOUS WASTE DISCHARGE O <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEL:01 II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF <br /> IN ATIO <br /> Name: � t Zo Phone: — v� <br /> Company: >cle <br /> Address: IS, <br /> Designated Employ e Name:f P f/ f1` ,�k-- Phone: �) <br /> Reporting Agencyame: <br /> Address: <br /> C. LOCATION AND DTE OF DISCHARGE <br /> Location: :. '' _-' / 'S-J�L-K-1 •� <br /> (Best Physcal Description) or County) Circle One <br /> Date of Discharge: / --�— -- <br /> Date Notified: Aq– Time: <br /> D. RESPONSIBLE PER ON/BUSINESS <br /> Name of Business: <br /> Contact Person: o Telephone: (2LD <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> •z <br /> Volume: <br /> Chemicals: <br /> Circumstances: 1 G2�L <br /> C%►�t ��.i�2"`G-y Lei w 6-6-a-z- Te- S PiL�2c c l .�N� <br /> F. ACT ON TAKEN a <br /> c2, - c �n- <br /> - e <br /> � t <br /> j 1 <br /> _ iC <br /> SITE STATUS <br /> �1�-- <br /> t t <br /> EH 22 013 (Rev-4/91) <br />