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SAN JOAQUIN COUNTY <br /> ILE COPY <br /> YOTIF'ICATION OF HAZARDOUS WAST DISC$A, <br /> 1 <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EME <br /> RGENCY LEVEL: i II w PHS-EH LOG �? <br /> (Circle one) <br /> g. SOURCE OF INFORMATION Lj <br /> Name: <br /> �� Phone: y�J� - v ,LSC f� <br /> Company: <br /> Address: Phon 6 , <br /> Designated Employee Name: <br /> 5 <br /> Repotting Agency Name: S 70 [ C f> <br /> Address--- <br /> C. <br /> ddress:C. LOCATION AND DATE OF DISCHARGE S�rcl <br /> Location: /,S- � 1 (City or County) Circle one <br /> (Best Physicai Description) <br /> Date of Discharge: L Time: I Nl <br /> Date Notified: <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> Name of Business: Phone: <br /> Contact <br /> Contact Person: 9 O TCS c,0 <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Cr✓ GF-1,S�r--ice"�'�L'L� ` � � ' <br /> Volume: _ <br /> C <br /> Chemicals-. 0/ _v L L 5 v C � �e} [A 1 Ac�' <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION ' Tint <br /> 11 �1 -.� v N AA <br /> ,eo�U0 C <br /> `AAJ <br /> EH 22 0 L3 (Rev_OSP-0198) <br />