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SO 30A�OUS WASTE DISCHARGE <br /> COUNTY <br /> NOTIFICATION CODE 25184.7 C(DPY HEALTH & SAFETY <br /> PHS-EH LOG # O 5 5 <br /> A- EMERGENCY LEVEL: I <br /> (Circle e) <br /> g, SOURCE OF INFORMAT14N <br /> Phone:11 <br /> Name: r 44-b <br /> Company: E. Phone: L a Se' <br /> Address: <br /> Desigvated Employee Nam= eg <br /> R.eperdng Agency Name <br /> Address: F. e <br /> �. LOCATION AND DATE OF DISCHARGE / Circle One <br /> Location• 3 k S ' #�� (�tY Co <br /> (gam physical Descripdon) <br /> r <br /> Date of Discharge: <br /> Date Notified= <br /> c - - <br /> D. RESPONSIBLE PERSON/BUSINESS r /,.y/ <br /> Telma; <br /> Name of flusineSS' •. <br /> Contact Person: _ y� <br /> Physical Address: , 0, ax �'` 9 <br /> Mailing Address: <br /> E. DESCRIP'T'ION <br /> Type of Discharge: <br /> volume: <br /> GKN <br /> Chen-dcalS: 501,rw... <br /> c <br /> ances: - <br /> CtCc <br /> F, ACTION TSN <br /> l <br /> SITE STATUS F Ce S <br /> EH 22 013 (Rev.4/91) <br />