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SAN JOAQUIN COUNTY <br /> NOTIFICATjt5fq OF aAZARDOUS WAS <br /> TE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> 3 <br /> A. EMERGENCY LEVEL <br /> (Circle One) PHS_EH LOG # /CX <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> Company: Phone: �) <br /> Address: <br /> Designated Employee Name: <br /> Reporting Agency Name: Phone: <br /> Address: <br /> LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Des prion) / <br /> Date of Discharge: City or County) Circle One <br /> Date Notified: <br /> L Time: <br /> RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: •��V <br /> Contact Person: , <br /> Physical Address ' ''`'� Telephone: ZD <br /> Mailing Address: <br /> DESCRIPTION <br /> Type of Discharge: k <br /> Volume: <br /> Chemicals: <br /> Circumstances: r <br /> ACTION TAKEN <br /> � f <br /> i <br /> t <br /> SITE STATUS f <br /> P <br /> t <br /> 013 (Rev.4/91) <br /> t <br />