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SAN <br /> UINI COUNTY <br /> NOTIFICATION OF HAZ�ARDOUSS WASTE DISCFIAR(�E'L E COPY <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG# O 1 — Q5--4— <br /> ((ircle one) <br /> B. SOURCE OF INFORMATION <br /> Name: .9to��� Nom.mo�,i Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: l 2,3 l to <br /> (Best Phys al Description) (City or ount ) Circle one <br /> Date of Discharge: ( Z d <br /> Xk <br /> Date Notified: Time: �I�oU�Q <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: .r M <br /> Contact Person. , Phone 6 3� <br /> Physical Address- <br /> Mailing Address: C) 0 <br /> E. DESCRIPTION <br /> e <br /> Type of Discharge: L4 <br /> Volume: 100 Z45 ' <br /> Chemicals: - a- <br /> Circumstan es: 2 ,b .� <br /> F. ACTION TAKEN L. k, e s <br /> SITE DISPOSITION c e <br /> Lve <br /> , <br /> EH 22 013 (Rev. 08/20/98) <br />