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r... SAN N COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE (CO py <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELII III PHS-EH LOG # 7Y-1, / <br /> ( 1rcle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: w�C CA ?5,v-.aA�..a,,.i�..P 1 <br /> Address: ,GTr ,4 4lN- <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:/ G C 4/ t,/a , / <br /> (Best Physical Description) Ci or County) Circle One <br /> Date of Discharge: a WK.wn,.M <br /> Date Notified: /c_ � Tz Time: j! vv�rr <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: cP�. J�ne_u•i_.A <br /> Contact Person: —W, .4.ea Telephone: 4,4-) 94 Y 6706 <br /> Physical Address: <br /> Mailing Address: .40- 6Q)e /zsrv' 14-111 <br /> E. DESCRIPTION <br /> Type of Discharge: f�ka !�_�_ uoP o jlez,�49 <br /> Volume: Uwu-K,nm <br /> Chemicals: �0ez r_f 00 <br /> Circumstances: ri rx.✓'zax cQ...,-H.� d-u.+.k, n�lJ<.L�i'L.• . <br /> F. ACTION TAKEN ��oLn 8 r./ a�. xt� resw/�• <br /> SITE STATUS <br /> �c�, <br /> EH 22 013 (Rev.4/91) <br />