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4 SAN JOAQUIN COUNTY J& C�� [ �o <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE F ` P+ <br /> HEALTH & SAFETY CODE ?5180.7 <br /> PHS-EH LOG = �� o l 5 <br /> A. EMERGENCY LEVEL( Iircle one) <br /> B. SOURCE OF INFORMATION <br /> r � � �0.`ZCJ(C � z <br /> Phonelfw 9 ( UFno <br /> Name: uv� �- <br /> Company---s c <br /> Address: 4S 1 `l S t nh y"g gp 3 <br /> Designated Emplovee Name. Diti� gar <br /> Reporting Agency Name: LQ_k k& <br /> Address: zc��l F vJeber Ata krcQ� koi Cf� RS�Z <br /> C. LOCATION AND DATE OF DISCPUARGE <br /> `k-� n C�L. <br /> Location: City r County) Circle one <br /> (Best Physical DescnpnoR) <br /> Date of Discharge: Time: <br /> Date Notified: 12 1 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Phone: 5 d <br /> Contact Person: <br /> Physical Address: <br /> Nlailing .Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: / <br /> F. ACTION TAKEN < Z31,�P��Y <br /> O ' <br /> Celt t4p, <br /> SITE DISPOSITION _ <br /> EH 22 013 (Rev. 031^_0/93) <br />