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S.A.Y JOAQLZY C0TUT TY <br /> NOTMCATION OF EL Z-- RDOtiS WASTE DISCHARGE <br /> HEALTH .& SA-FETY CODE '_I30_? <br /> A. EMERG—ENCY R tII ?FS-EH LOG= 99 - / 03 <br /> ae:e one) <br /> B. SOURCE O,(FINFOR:vLk'MON <br /> Name: 0 t t ICL ��/LfQ L ohoae: ( ) <br /> Commav: F'S <br /> Address: <br /> Design, d Emoiov=Name: Phone: oeq f/6 ?4S <br /> Regorvng Ageacv Name: <br /> Address: 2)6111 r <br /> C. LOCATION iNFD DAT'c OF DISCHARGE <br /> Loc=oa:7llll� • <br /> Bes. Phvsi Descrianon) (CXv Circ:e one <br /> Dare or Disc^= : a 99 <br /> Dace NoaEcd. d% x/94 rme: YJ�Om— <br /> D. RES?ONSIBLE ?25ONBUS24ESS T <br /> Name ri 3usness: Yoc a ra,l J d� <br /> C0umc, ?=0a Ur O ma i ?hone: 3 -cc o�— <br /> ?!4vsic[ Address: <br /> N[:iling Address: (-� <br /> E. DESCR=70N <br /> Type or Dis,-^,,e: <br /> Volume: -ro <br /> Cae.•niris: % i <br /> C.rcums=c=: ,r <br /> F. ACTION T>K.eV <br /> SITE DIS?O=ON /Vd l/X <br /> ='? == J t] i,Rn•. 03.':0/93) <br />