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SAN JOAQUIN COUC PHARG NOTIFICATION OF HAZARDOUSASTE DI ® <br /> HEALTH & SAFETY CODE 25180 . 7 <br /> A. EMERGENCY LEVEL: II II III HEALTH DISTRICT LOG # G/ Z— <br /> (Circle One ) <br /> B. SOURCE OF INFORMATION <br /> Original Source: b� r-, L ��)�cp� Telephone: (�)� <br /> Reporting Agency Name: �p L i� �q � <br /> Agency Contact: �� ��. g� Telephone: (X9 ) g- <br /> Address : (01)\ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: u A�1C1 191111 <br /> Date Notified: _ � � �qa�j Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> / <br /> Name of Business F,IL ( 0k)STQL:CXjAr,) <br /> Contact Person: L RO!�1L Telephone: ( ) <br /> Physical Address : <br /> E. DESCRIPTION <br /> I <br /> Type Blease: ��U1ti(llie�t� <br /> Volume : K)KA <br /> Chemicals : <br /> F. ACTION TAKEN <br /> �ur P err A�S�SAi T WILL i� r�lnu �� 7� T�r,r n�l � ,� TltE <br /> Ff <br /> WAE, hr tms-o me Nle -(D <br /> w r 791- (t �u 2c�s Ctq.,,QAen— <br />