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SAN HAZARD COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE (LOUu — <br /> ED <br /> HEALTH & SAFETY CODE 25180. 7 <br /> i <br /> i A. EMERGENCY LEVEL: 0II III PHS-EH LOG # Ll <br /> (Circle One) <br /> B . SOURCE OF INFORMATION // <br /> Name: Tif�t&I /%1JZ11� I Phone : v <br /> Company: / <br /> Address : U , e S Gr9 <br /> Designated Employee Name : S Phone: 6:0 <br /> Reporting Agency Name: 61h Az 45Z zmpnioa�jy rzj2-;) <br /> Address : n rdotrzZ4 e4 <br /> C. LOCATION AND DATE OF DIS <br /> Location: / 3D N' f�i/✓/ / / <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge : <br /> Date Notified: i/ b Av Time: _ �U✓� <br /> 0 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business : <br /> Contact Person: w Telephone: C9-02 ) <br /> Physical Address: o <br /> Mailing Address: c <br /> E. DESCRIPTION <br /> Type of Discharge : <br /> Volume : /t27 /"/4)71 <br /> Chemicals : <br /> Circumstances : 1 r <br /> US � nc�m�i <br /> F . ACTION TAKEN c ZL <br /> ll � ( r <br /> SITE STATUS 61 A00 <br /> EH 22 013 (Rev.4/91 ) <br />