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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # `7 0 13 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: , ) ' 73 <br /> Company: 1j <br /> Address: <br /> Designated Employee Name: C'. P Phone: <br /> Reporting AgencyName: <br /> Address: <br /> C. LOCATION ANDD TE OF DISCHARGE <br /> Location: 3.3 ? <br /> (Best Phy ical Descri ' ion) <T�i'or County) Circle One <br /> Date of Discharge: Gr',�-7 k <br /> r <br /> Date Notified: A 5 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS Q <br /> Name of Business: 2 <br /> Contact Person: Telephone: <br /> Physical Address: 4 -S <br /> Mailing Address: S%ia <br /> 79 <br /> E. DESCRIPTION /1 <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: z - <br /> C'rcumstances: <br /> i O <br /> ' tL <br /> F. ACTION TAKEN <br /> o <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />