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SAN JOAQUIN COUNTY *W <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:GI II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: O r.r0/ 0 e-- Telephone: <br /> Reporting Agency Name: � c� <br /> Agency Contact: Telephone: { r ) _ • f�4, 3�/L• '. __. <br /> Address: I/ C/ , .�✓� . <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: a <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: �r►- <br /> Date Notified: /O-/If--if Time: '0���'� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business Ice - <br /> Contact Person: Telephone: <br /> Physical Address: gas V <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: .� <br /> Chemicals: <br /> F. ACTION TAKEN <br /> - $5 C[ic 7'T� �YG7f-77 /?D Gl /�GG'Gv �7�' �•/� [:Y7 `l1 /7 t r74'Jt'{l/1 <br /> 5 U!i t�lJ f� CT r G• �•!-� ! ! � c' �'�Jt c � <br /> EH 22 03 (Rev. 7/89) <br />