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�-' rA.N JOAQUIN COUN , <br /> NC'TIC'MON OF =iAZAR OUS WASTE DISCFARGE <br /> HEALi rz & SAFETY CODE 25180.7 FILE COPY <br /> A. EMERGENCY LEVEL: I <br /> ( II III <br /> PHS-EH LOG <br /> Circle One) <br /> B. SOURCE OF INFORMATION Phone: Z Jf <br /> Naive: �� <br /> COZnDanv- s / <br /> Address: �O2 Phone: <br /> Designated E=Dloyee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCf�iAR <br /> Location: /S0 v City or County) C rcle One <br /> (Best physical Description) <br /> Date of Discharge: Time: -S <br /> Date Notified: <br /> D. RESPONSIBLE. PERSO/ELT INESS <br /> Name of Business: C�r� Telephone: r .) g �Z- <br /> Contact Person: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: ' <br /> Volume: , •-7n�-p�E- <br /> Chemicals: <br /> Circumstances: <br /> C <br /> F. ACTION TARN-------------------- <br /> SIT✓' STATUS — <br /> F <br /> r-- <br /> E:122 013 (Rev.4/91) <br />