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NOTIFICATION Or �IAIARDOUS WA.F"M DISCHARGE <br /> HEALTH & SAFE-INCODE, ,.0180.7 <br /> r <br /> ,2) <br /> A. EMERGENCY LEVEL: I U III PHS-E-1-1 LOG # ` <br /> (Circle One) <br /> D. SOURCE Or, INFORMATION <br /> Original Source: Telephone: `1/5 <br /> Reporting Agency Name: SG o 5 ' F« 0 <br /> Agency Contact: Telephone: 2�} 'fh S- 5(5-el- <br /> Address: <br /> Ad dress: G 4 .� ,f.-, ['cr c S <br /> C. LOCATION AND DATE Or DISCI-L .RGE <br /> Location: ZeW ,ill % �-ruda r <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: Z:? Y� d Time: <br /> D. RESPONSMUS PERSON/BUSINESS <br /> Name of Business c ✓ �ri , `sus <br /> Contact Person: Telephone: Zo`z S zc�v <br /> Physical Address: 401 <br /> E. DESCRIPTION / <br /> ' 7ype Release: �:�; oV41`t-/ c�,r7�i�l�srct�07 r :1 kreol 44 -" k4V2 1 <br /> Volume: <br /> Chemicals: / ���c.%'c' %� ,��C�r4v lev-1 -c— <br /> F- ACTION/TAKEN <br /> Y1 U <br /> VJJYI II �+ /1G /I 4C7`f� ii1 C* <br /> LL-- e c-c.,f >Z C <br /> )6 f7 C S _ Y ✓ 5 A S �� <br /> i <br /> C 71 r t f <br /> E-H 22 013 (Rev. 02/90) <br />