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SAN HAZARD COUNTY IS (/ "O Py <br />NOTIFICATION OF HAZARDOUS WASTE D[SCHARG 1��_ O <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVELL, <br />II III <br />( ircle One) <br />B. SOURCE OF INFORM <br />Name: SfeVe, <br />Company: <br />Address: . o, <br />Designated Employee <br />Reporting Agency Naj <br />r-r-r�- <br />C. LOCATION AND DATE <br />(Best Phy <br />Date of Discharge: <br />Date Notified: <br />D. RESPONSIBLE PEI <br />Name of Business: <br />Contact Person: <br />Physical Address: _ <br />Mailing Address: _ <br />E. DESCRIPTION <br />Type of Discha <br />Volume: z <br />Chemicals: <br />F <br />/ufa- <br />Time: <br />PHS-EH LOG # � - eM- <br />Phone: /D)k�.l <br />/ i �;OL `F 372 <br />(City or County) Circle One <br />Telephone: <br />EH 22 013 (Rev.4/91) <br />