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SAN ,rOAQU1i`I COUNTY ��� COPY <br /> NO'T'IFICATION OF HAZARDOUS WASTE DIS <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG T 03 ' 6—10 <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: " 1t(I%lr& t O Phone: { ) <br /> J <br /> Company: (-733 <br /> Address: Z4 e <br /> Phone: <br /> Designated Emplovee : me: �irAtt , k2,�L <br /> Reporting Agency <br /> Address: 30 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: Ci or County) Circle one <br /> (Best Physical Description) <br /> Date of Discharge: J T* e: <br /> Date Notified: C. 3 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> 9 � $ Y-57 tno <br /> Name of Business: Phone: $___ <br /> Contact Person: ,2�p &1,..ro, k 30 <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: V <br /> Volume: t <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.08/20198) <br />