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SA;', JO�,QULN COUNTY <br /> N OTIF ICAT10`I OF H.-�.ZA"OUS WASTE DISCH kRGEF I L E COPY <br /> HEALTH & S.AFETY CODE ?5180.r <br /> A. EMERGENCY LEVE : I II III <br /> PHS-EH LOG 9 ' �� � OO 3 <br /> irclz one) <br /> B. SOURCE OF INFORMATION <br /> tiame: <br /> R,�,oS hk <br /> Company: <br /> Address: ��/ �� �� <br /> Phone: r' � <br /> Designated Employee Name-. <br /> Reporting AgencyName: s Z <br /> Address: <br /> C. LOC.�TIONti� DATE OF D1SCI-LARGE <br /> Location: (City ar ounty' Circle one <br /> (Best Physical Descm ion) <br /> Date of Discharge: / �' % <br /> - Time: / <br /> Date Notified: <br /> D. RESPONSIBLE P£RSON/BC;SINiESS <br /> Name of Business: Phone: <br /> Contact Person: T`; rte. ' m— <br /> Physical address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> T%-pe of Discharge: - �ds cif/ <br /> Volume: 7Gi <br /> Chemicals: - � i--v�— <br /> • <br /> Circumstances: <br /> F.' ACTION TAKEN <br /> SITE DISPOSITION <br /> EH 22 013 (Rei•, 090"0193) <br />