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NOTIFICA NOF HAZARDOUS WASTE:'OISC '.AGE � <br /> FALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: [I III PHS EH LOG # <br /> (Circle.One) <br /> 3 B. SOURCE OF I FORMATION , <br /> Name: L�h$ S � o Wos ,,' Phone: <br /> Company: W <br /> Address: yS/j 3 eo u A44(4 y&-f- g-s- X/6 --- <br /> Designated Employee Name: !11: Phone: (2gL)_,-[(OY- 3 4 `i j <br /> Reporting Agency Name: C-- .�1a1'Fc t]P�isc-, SaJ►_�:�e� <br /> Address: s <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: S. �� !' / c//rte-• <br /> (Best Physical Description) 1 (Ci ..r County) Circle One <br /> sZ <br /> u /l s4,,,L,/ti <br /> Date of Discharge: Iii! <br /> F <br /> Date Notified: Lel,;� 7/1 3 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: _ cA u/c, ephone: Uo) `/66 -7f, . <br />` Physical Address: I� <br /> Mailing Address: -o.By K "K&Y, s <br /> E. DESCRIPTION <br /> , <br /> Type of Discharge: vncr i� ' <br /> Volume: <br /> Chemicals: / h. <br /> Circumstances: s ple- f 7` ,:. se <br /> i <br /> F. ACTION TAKEN ic,"k r.Jc. sy��,���-�/ -- ��i`t� °Y �s�i-.,,��� +• ._ <br /> wlo7l 4 <br /> SITE DISPOSITION �s �� �• <br /> _k / 'T <br /> EH 22 013 (Rev.4/91) <br /> i <br />