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0 <br /> 0 SAN JOAQUIN COUNTY rfb <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III - PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 1�- )C ► S L f-r^ c (` Phone: (±,&) <br /> Company: <br /> Address: <br /> Designated Employee Name: l.,z 1 4-� Phone: -2`t3j <br /> Reporting Agency Name: _ <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE / �6& <br /> Location: S'00 E lC.� i�� m Q�vU J <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: _ Z,,� — — lr/ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: /� �L p , <br /> Contact Person: 't-�Q 1; /L K, Tele hone: (4�5) �7/--�Y O O <br /> Physical Address: O _ _ u.L 14 S <br /> Mailing Address: 12 rp, 17� <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: ko <br /> Circumstances: Ile <br /> F. ACTION TAKEN <br /> / <br /> G <br /> Lei <br /> SIT DISPOSITION — SS -5 �- <br /> � <br /> EH 22 013 (Rev.4/91) <br />