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SAN J0AQUPIi COGyTY r� <br /> NOTIFICATION OF $,-XZARDOUS WASTE DISCH.AR � <br /> HE:,LTB & SAnTY CODE 25180.7 �- ,I <br /> A. Ey1ERGENCY LEVEL: I II III PHS-EH LOG 9 f Z <br /> (Circle one) <br /> SOURCE of INFORMATION <br /> dame: Phone: (JD? <br /> Comoanv: <br /> ?Address: <br /> Designated Employer Name: i Phane: �4 <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION IN-D DATE OF DISCHARGE <br /> Location: 3- 33 A), Al firt1 pG <br /> {Best Physical Description) (City o ounty Circie ane <br /> Date of Discharge: <br /> Date Notified: r T►me. <br /> D. RESPONSIBLE PERSONB[;SIyESS <br /> Name of Business: <br /> Contact Person: 5 G 0 Phone: 07 <br /> 01 aysmcai Address: f' <br /> V(ailing _address: : O• �` <br /> E. DESCRIPTION <br /> Type of Discharge: Gli �S <br /> Volume: <br /> Chemicals: D <br /> ClrcurnstnnCts: 62_ <br /> �r- <br /> F. ACTION TAKEN <br /> /a/ <br /> SITE DISPOSrPON <br /> • � C <br /> 191 22 1-1 (Rev. U8/_4/98) <br />