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1..r S A`+ .JO A Q LrLN C O LNi TY *-00 <br /> `OTUICATION OF H.kZARDOUS WASTE DISCELARGEC(Opy <br /> HEALTH 34 SAFETY CODE 2S180.7 <br /> A. EMERGENCY LEVEiI III PHS-EH LOG r � � �'60 <br /> Circa one) <br /> B. SOURCE OF NFOP-MA-TION <br /> Name: Phone: <br /> Comoanw TI7 <br /> Address: <br /> Designated Emplovee`lame: Jf. Phone: <br /> Reoorung a-encs Nacre: vl <br /> Address: ;*:K <br /> C. LOC aTION ?.NDDATE OF DISCHARGE <br /> Locauon: 7_ it ' <br /> (Best Phvsicai escriotion) C County) Circe one <br /> Date or Discharge: <br /> Date Time: <br /> D. RESPONSIBLE. PERSONM SINESS <br /> Name or Business: / tz <br /> Contact PQ-Son: / c Phone: ,, -% .Z, <br /> PInvsicai Address: c9 )� C (% / ` ••T ��• -- <br /> Malliniz _address: -7 //c.•' �� <br /> E. DESCRIPTION <br /> T,,-pe or Discharge: <br /> Volume: <br /> Che, Icais: <br /> Circ,msranczs: <br /> F. ACTION T.aKEN ZG� e <br /> SITE DISPOSITION <br />