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_ SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> PA. EMERGENCY LEVEL: I II III HS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (HIE)-� � 3H� <br /> Company: /7�G ;-o .r,�• �. <br /> Address• 7; '� <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C: LOCATION AND DATE OF DISCHARGE ` <br /> Location: U <br /> (Best Physical Description)/ OCity r County) Circle One <br /> Date of Discharge: " <br /> Date Notified: 174 9 Time: <br /> D. RESPONSIBLE PERSON/BUSIN SS / <br /> Name of Business: �a rGs <br /> Contact Person: `r Telephone: W,3 <br /> Physical Address: / ,-. i� o G'O, o, <br /> Mailing Address: �. 4 rLcr `70~ <br /> E. DESCRIPTION F <br /> Type of Discharge: <br /> Volume; <br /> Chemicals: <br /> Cir umstances: <br /> i <br /> F. ACTION TAKEN <br /> JA, O Ci�',Y'�'d C� 7�/ rot■'/r <br /> SITE DISPO ITION �'' � �f cls <br /> i <br /> ,N <br /> r <br /> EH 22 013 (Rev.4/91) <br />