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AT SAN JAZARD COUNTY „".c C 0 Py <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE • <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I li III PHS-EH LOG # os <br /> Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: ?) ( t v S Phone: (a0b Lief 396G� <br /> Company: <br /> Address: <br /> Designated Employee Name: ' cz_ 1 Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE 1 <br /> Location: 37.5 `H19C Y C l/ <br /> (Best Physical Descriptio ) (City or County) Circle One <br /> Date of Discharge: 3 -3k 9- � Lo <br /> Date Notified: -,� q— 17& Time: 2. C,4217 v <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: &t/D <br /> F Contact Person: / ,���cL_�cr�7`G', Telephone: -�-75-0'700 <br /> Physical Address: <br /> Mailing Address: )� S 5� r: I U <br /> a-rv�rn�yv; v�5�3 <br /> E. DESCRIPTION <br /> Type of Discharge: AzWk- <br /> Volume: �v� <br /> Chemicals: <br /> Circumstances: <br /> CCS <br /> F. A ION TAKEN <br /> SITE DISPOSITION ' <br /> EH 22 013 (Rev.4/91) <br />