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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 6:)11 III -EH LOG # <br /> (Circle One) COPIT <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: ,..G <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: �>�<� �1/ -����r� 0iJ���<� <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSO�i/BUSINESS <br /> Name of Business: f/ y/�,d co// _�,,,��t�' f,�i io,�/ �'E�'✓iG- . <br /> Contact Person: 44' Telephone: IZ,). �y� - a�?:'7 <br /> Physical Address: , -- <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: liA4,4—' ioi'�zc/7 <br /> volume: <br /> Chemicals: <br /> Circumstances: ���/ '��/� � Tj//� /���!G7�;�'t_ /�G'�G�x� Lc,^f�-il-=rii✓<�7'it�� <br /> F. ACTION TAKEN <br /> SITE DISPOSITION �!�/�C� =��clr'� ���• � ��/K �� %�'�i�,.���o�/ <br /> Q �G� AL. <br /> - <br /> �il/G'E�r/'/Gs�o/�� �i�l� �'F.r+�i'��d>i�� �Wil-ti% f� �E����G•> >?f' <br /> EH 22 013 (Rev.4/91) <br />