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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: �J II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: r n�� 1"� l n{ Phone: (LI)93z- of S`? <br /> Company: R <br /> Address: <br /> Designated Employee Name: Phone: (___) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 1/7,n9 i. Wtl 6;6"',- Pam+ <br /> (Best Physical D scription) (City or Coun Circle One <br /> Date of Discharge: & 177 <br /> Date Notified: '?// 2 ) Time: !�-:,V p <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: P(, • ' E . <br /> Contact Person: Telephone: 77 Ve 7 3 <br /> Physical Address: 3 o o Gam' C��— R�^"�� (A 14-17 <br /> Mailing Address: <br /> E. DESCRIPTION , <br /> Type of Discharge: P � -e — — Lu'"t' <br /> Volume: _ <br /> Chemicals: <br /> Circumstances: 4A49L JM U <br /> tirr�-EP ,y <br /> F. ACTION TAKEN_ �..� �,u+-� wry" .�ofc a--� �Ltp-r�N.• ��� �X,�a' <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />