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in SAN JOAQUIN COCNTY <br /> NOTIFICATION OF HAZARDOUS ASTE DISQ. ARGE <br /> HEALTH & SAFErf COD 25180.7 <br /> I <br /> A. E.c�rSERGE��TCY LEVEL• I CQ PHS-EH LOG # <br /> �e One) _ n <br /> i <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> Campany: Phone: <br /> Address,- <br /> Designated <br /> ddress:Designated E.-nployee Nam . Phone: L� <br /> Reporcing Agency Name: �o <br /> Address----30 r -a <br /> zv 2_ j <br /> �:. LOCATION AND DATE OF OISCrIARGE <br /> Location:3 `s <br /> CBesr Physicalesciption) <br /> Dare of Discharge; I A . . •r7 r COuary) Circle One <br /> Dare Noened: -7 Tis;e: ��p <br /> . R.ESPONSMLF- PERSON USDIES <br /> R <br /> a <br /> Name of Business- 7 <br /> Contact Person �3 Teienhone_ <br /> Physical Address: -- <br /> MaiHng Address: 20 <br /> DESCRIPTIO N <br /> Type of Disch xar-- <br /> Volume: <br /> Caernicais: <br /> C:rcumsrances: <br /> NLea 1 <br /> ACTION TAKEN <br /> SITE DISPOSE'17.0 <br /> 22 013 (Rev.4/91) <br />