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-- A <br /> NOTIFIC A.70N OF HAZARDOUS WASTE E D1SCFARGE _ <br /> IEALTH & SAFETY CODE. 25180.7 <br /> A. EMERGENCY LEVE' . I E PHS-EH LOG ' S [i G <br /> ce on--) . <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> Company: Phone: <br /> Address: <br /> Designated Employee Name.- Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF MSCHARG <br /> Location: lyQQO ;t Z } <br /> (Best physical Dec�itation) (City oroun Circle One <br /> Date or Discharge: <br /> Date NotLEed: Z;.a LJ Time: 12:o �� <br /> D. RESPONSIBLE PERSON/BI;S`LNr--SS <br /> Name of Business: i ova-c-c- ��Lr lz, <br /> Contact Person: v0 res. Mpbe Telephone: <br /> Physical Ad(Lress: IL"'G Oc 1 f� <br /> Mailing Address: �r-z <br /> E. DESCRIPTION <br /> r <br /> Type of Discharge: -.:�C L t <br /> Volume: _ {)rLKnc' -,o (' <br /> Chemicals: c C L <br /> Circumstances: ern') .�© 0►^ r2c <br /> f V a <br /> F. ACTION TAKEN <br /> LIJas -,� S ill was t �wc f <br /> s 11 <br /> SITE STATUS <br /> U <br /> EH 22 013 (Rev.4/91) <br />