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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE n <br /> HEALTH & SAFETY CODE 25180.7J ' <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <` — S <br /> ( rcle One) <br /> B. SOURCE OF WORMATION <br /> Name: Phone: 3 —7.07� <br /> Company: A A Gam' G <br /> Address: 6 G0 - �7-,0e-&7Z)A1, j <br /> Designated Employee Name: •cam- Phone: <br /> Reporting Agency Name: f} J <br /> Address: . 0 <br /> C. LOCATION AND ATE OF DISCHARGE <br /> Location: �" .SSG Com- Gj�2L1 <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: r'a u <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: —?p <br /> Physical Address: / Al GAr- <br /> Mailing Address: x 12 p 4v G 9S <br /> E. DESCRIPTION <br /> Type of Discharge: CSA Z <br /> Volume• - ," <br /> Chemicals: e3n r,►. �'� C r4 P S i <br /> Circumstances: d c� <br /> F. ACTION TAKEN 4A 110 n/ jd <br /> v//r,� /C G✓ <br /> Yep a.--7— <br /> f G✓.tJ eit <br /> SITE DISPOSITION <br /> � - Ile— A1C <br /> G <br /> EH 22 013 (Rev.4/91) <br />