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SANALkRD COUNTY �OD� <br /> NOTIFICATION OF HAZAR.DQUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A, EMERGENCY LEVEL: it II[ <br /> PHS-EH LOG <br /> ( ircle One) <br /> B. SOURCE OF-INF RMATIO� Phone: ZU N6 & -5/ 9 <br /> Name: <br /> Company: rw 4- ^ 4. -, <br /> Address: S L�n4�'� r' Phone (� <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DILCHAKE / <br /> Location: J l4 W ( JJ�IJ� IBJ--�-- ( or County) Circle One <br /> (Best Physical Description) <br /> Date of Discharge: Time: <br /> Date Notified: 17(0 l <br /> D. RESPONSIBLE PERSON/$US[� SdS TYi�6n�A <br /> Name of Business: d�oo Telephone. lr� <br /> Contact Person: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: U/Yl <br /> Chemicals: a <br /> Circumstances: <br /> F. A ON T N <br /> SITE D[SPOSTTION <br /> (pl✓- A,r�! ay V <br /> X <br /> EH 22 013 (Rev.4/91) <br />