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SAN .FOA UIN C UN <br /> 4 TY <br /> NOTIFICATION OF HAZARDOU3 WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL.00II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: JEe?-Y �'/n_SktoxA Phone: <br /> Company:T �� - — - ~._ Ean���a� .� -tom.( c . <br /> Address: <br /> Designated Employee Name: Zfc 1' h,o d Phone: zog �10 8-osss <br /> Reporting Agency Name: San 6- vcrovl.,�c,�fa.( Ica.(4h <br /> Address: 30A} E cS6- <br /> C. LOCATION AND DATE OF DISCHARGE r _ <br /> Location: t32S (20q--aA o�(ow / T <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: l 1n'ky-cawv% <br /> Date Notified: `lune 19-s l qq—+ Time:— <br /> D. <br /> ' e:D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Trx <br /> Contact Person: li Telephone: (� $,3 -2890 <br /> :Physical Address• <br /> Mailing Address:. moo, Bnx 1OS(6 CA 4 SU <br /> E. DESCRIPTION <br /> Type of Discharge: +n a�-•�noK-arc d <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> Cxr*� n cn <br /> F. ACTION TAKEN <br /> .w <br /> SITE STATE'S mnal <br /> EH 22 013 (Rev.4/91) <br />