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JAN JUAQUIP4 l.Vul't i <br /> NOTIFICA` J OF lIAZARDOUS WASTE r` - `T ARGE <br /> �zl�? LT1I & SAFETY CODE 25180:: <br /> A. EMERGENCY LEVEL: I ' 7I IIIA ,'PHS-EH LOG <br /> (Circle One) L <br /> B. SOURCE OF INFORMATION <br /> Original Source: ���! �L-�,'F1� Telephone: '`T <br /> Reporting Agency Name: <br /> Agency Contact: glC �R�1�F-r�ll�- Telephone: �'oa X165 ��2`T j <br /> Address: ��f 5• ic/'- SILf/ �'or�4v��( <br /> C. LOCATION AND DATE OF DISCIIARGE <br /> KA!�� _ c cc%6 / Uc- art , <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: �/-26 -��J Time: — <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business ` L Y Ca z�1L <br /> Contact Person: Telephone: <br /> c } <br /> Physical Address: P- <br /> E. <br /> E. DESCRIPTION <br /> Type Release: ��v4�-rGR���r� � EA <br /> �F ,ye-r� v���ruF <br /> Volume: (' ' ` UAll <br /> Chemicals: <br /> E%Lh��lZt/f� <br /> F. ACTION TAKEN s o �L 2�u[.Ts �� �� 2�-��� �,✓��c,4?c <br /> - <br /> fG 14 s-5 i5 s,-,E� 4-(4,1— /3F )eF-A4 -7D A5-TTE)een N F <br /> Nay .4 rV 19 25�>rl—D c�nIT,Q�-t rN77r S �2�4=vr lTJ 1S`r' i'N F <br /> EII 22 013 (Rev. 02/90) <br />