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--- -� • •+v�•�e�•J1v �.vtriVl a <br /> NCtixIrICATION Ol� I-LklARDOUS !' STE DISCHARGE <br /> `., IiEALTI Y & SAFE`T'Y CODe 25180.7 <br /> A. EMERGENCY LEVEL: U III PHS-EH LOG # - <br /> (Circle One) <br /> D. SOURCE OF INFORMATION <br /> Original Source: T T Telephone:, /I5 3-7? -11 co <br /> Reporting Agency Name: Sc,in \oGN cc:li V1 �y ouW is �c�� Servlcrs ��ib <br /> Agency Contact: Telephone: (Z�?s ) y6 Fr-3 y�s• <br /> Address: Y11 5 4/. Sr-, cpG � k-„ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /'/0--,, c o.,n-W C l u k tion <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: 1/0 k✓l0L✓r1 <br /> Date Notified: 7-�2 6 -5 5 v Time: <br /> D. RESPONSMLE PERSON/BUSINLSS <br /> Name of Business <br /> Contact Person: _(� , ,�, I I i s Telenhone: I - D 7 33 <br /> Physical Address: 2A G'S eros Rcncl, , Co�c�c��c� <br /> E. DESCRIPTION �S C�70- .6 0 <br /> Type Release: —C(9 �► }���, ��r f� IdI I - 1 <br /> '' � i�n ;r n CJI,'1r�T'�'✓ tJ i ci�n i IA'�ic t--2° <br /> Volume: — l 1✓1 el 0( f Y) <br /> Chemicals: —ile✓1 ze� Ori <br /> F ACTION TAKEN <br /> EH 22 013 (Rev, 02/90) <br />