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• �itQivw�,—e <br /> COPYSAN JOAQUIN COUNTY <br /> N TIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVE : I II III PHS-EH LOG # <br /> Circle One) <br /> B. SOURCE OF INFORMATION ZZ6`� <br /> NPhone: <br /> Name: <br /> Company: �- <br /> Address: t o c.1c i� (/- <br /> Designated Employe ame: Phone: (_) <br /> Reporting AgencyName: <br /> Address <br /> C. LOCATIO ANDD TE OF DISCHARGE St� tr� <br /> Location: 3 v& / <br /> (Best Physical es ription) (City or County) Circle One <br /> Date of Discharge: /S FS <br /> Date Notified: Time: /0,'06 At, <br /> D. RESPONSIBLE PE SO/BUSIN�0_S , t <br /> Name of Business: I�- c L!s <br /> �• Co Telephone: (�(3 ) <br /> Contact Person: <br /> Physical Address: gP3 <br /> Mailing Address: Soo 90U1-�' <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: O <br /> Chemicals: 2— <br /> -aj <br /> Circumstances: ' <br /> F. ACTION TAKEN �-� <br /> SITE STATUS <br /> S �, we <br /> uu- <br /> EH 22 013 ( ev.4/91) <br />