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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE D1,,v�GE <br /> HEALTH & SAFETY CODE 25180.7 <br /> II III PHS-EH LOG # <br /> A. EMERGENCY LEVEL: (Ci cle One) <br /> B. SOURCE OF INFORMATION <br /> Telephone: <br /> Original Source: ,I 3�Za <br /> Reporting Agency Name: Telephone: ( 'IA°�) <br /> Agency Contact: <br /> Address: <br /> C LOCATION AND DATE OF DISCHARGE/ Lp <br /> Location: W'nom?F-- <br /> At N oT (City or County) <br /> (Best Physical Description) <br /> Date of Discharge: U Time: <br /> Date Notified: 17-61 I g <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> (09� <br /> Name of Business Sr+ Telephone: (2jS <br /> Contact Person: S-te_ r, o <br /> Physical Address: <br /> E. DESCRIPTION <br /> i <br /> Type Release: <br /> U <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br /> EH 22 013 (Rev. 02/90) <br />