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rru11P1c NlION OF IIAZARDOUS WASTE DISCHARGE <br /> "EAL.TH & SAFETY CODE SU.� <br /> A. EMERGENCY LEVEL:"I_)II III PHS-EII LOC # (p <br /> (Circle One) <br /> B. SOURCE OP INFORMATION \' <br /> Original Source: rOCJ-A Telephone: ' r <br /> Reporting Agency Name: F /c/ <br /> Agency Contact: LU /,(� 'f;��„J Telephone: <br /> Address: j' 0 , )q-6x .;� 60 O / <br /> C. LOCATION AND DATE Or DISCHARGE <br /> Location: 4t;c <br /> (best Physical Description) (City or County) <br /> Date of Discharge: %,-!,!. 4w <br /> Date Notified: �' `� <br /> 10 Time: <br /> D. RESPONSIBLE P -RSO /BUSLNESS <br /> Name of Business 1 t9' �+ 7<s <br /> Contact Person: r rx Telephone: (�Q� `f 7 s— / <br /> Physical Address: _D •Qtrl' /p'�G SQL C Kir (i�J x'15�l /O <br /> E. DESCRUMON <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> {� <br /> I• ACTION TAKEN <br /> a S�v P .S��,vr�r���• A 0 1 &AOO, <br /> v <br /> Q <br /> z <br /> EH 013 ( ev. 02/90) <br />