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TY <br /> SAN JOAQUIN COUN <br /> ti ,L- <br /> NOTIFICA i LtN OF HAZARDOUS WASTE DIS(.,MRGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> �f <br /> A. EMERGENCY LEVEL: ©II III PHS-EH LOG # q) — -1 (4 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: C!( ) s�:,) Y- 7 <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: , Y&f "V6 <br /> Reporting Agency Name: �7-oe,-Za ��•�/�� /1r���1 �,v<<Ps <br /> Address: z/ys A-,), saw Toa� U�� <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location•• 90 5- /I'Ic 4,-,� 4�- / �s c�to�, C� <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: uhkH <br /> Date Notified: /o-/(a - g� Time: 4111i?2 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: G2 f -7.a �/ <br /> Physical Address: /`lo - <br /> Mailing Address: sA ne <br /> E. DESCRIPTION <br /> Type of Discharge: - <br /> Volume: <br /> Chemicals: <br /> Circumstances_ v.i 5e; Ile- /11 r« cc�E, !;I= -j �nl <br /> F. ACTION TAKEN S,' v . <br /> SITE DISPOSITION s <br /> EH 22 013 (Rev.4/91) <br />