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Ilk <br /> COUNTY <br /> 01 F•l L P Y . . <br /> SAN oAQuuv C <br /> NOTIFICATION OF HAZARDOUS WASTE D€SCHARGE p <br /> HEALTH & SAFETY CODE 25180.7 <br /> t <br /> SYS <br /> F PHS-EH LOG <br /> A. EMERGENCY LEVEL=©R <br /> w (Circle One) _� '7' <br /> B. SOURCE OF INFORMA'T'ION Phone: <br /> Name: �' ulN 1 �s2� c <br /> Company: C P Q yA one: y"� <br /> Address: phone: (2oa) <br /> Designated Employee Name:� _ <br /> Reporting Agency Name: h ;'� <br /> Address: t . .. . :. <br /> C. <br /> LOCATION AND DATE OF DISCHARGE <br /> ,� s� Circle One <br /> Location: 3 ` . (City or County) . <br /> (Best Physical Dem p/on) n 3 <br /> Dare of Discharge: <br /> l �1��t5j Time: <br /> Dare°Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> � teP <br /> ho62 <br /> Name of Business: Te. ne: a ' <br /> y3i - <br /> Contact y� <br /> Person: iPv z �` `' 3(v i] <br /> Physical Address- � Ag 37,— <br /> Mailina Address: Co 9 <br />{ o <br /> I E DESCRIPTION .; <br /> Type of Discharge: <br /> Grvr � cc � vi � � <br /> volume: <br /> Chemicals: irp r F v <br /> i Circumstances: / <br /> r. <br /> ACTION TARN <br /> SITE STATUS �v <br /> EH 22 013 (Rev.4/91) x <br />