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SAN JOA U U <br /> . w. Q iN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH.& SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II I PHS-EH LOG # — <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: __ sc g� � ?A, ./7C< j Phone: �) <br /> Company: <br /> Address: &Y0 <br /> Designated Employee Name: l €' ic_c�r��r �,. „ Phone: 501 <br /> Reporting Agency Name: CcF c, Cd- <br /> Address: �J (1 c,'•, � � f , „ G- 5 z�i <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 7-7-7 L coc',w 3,)- / �`,ti� o <br /> (Best Physical Description) i r County) Circle One <br /> Date of Discharge: � � Lwe'l-7 <br /> Date Notified: 6—/L/ —q Time: e"004 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 41eep)er <br /> Contact Person: Telephone: { ) 5 9�L de 66 <br /> Physical Address: =7 4- gs <br /> Mailing Address: <br /> E. DESCRIPTION , <br /> Type of Discharge: ,Yrkwe�'�e�5co.-r �i�G L✓Gs r� CIA,/ <br /> Volume: <br /> Chemicals: fro eve <br /> circumstances: v1 -X; 9f /IT <br /> F. <br /> F. ACTION TAKEN <br /> U;nc_ <br /> fA Ar <br /> caw ti� v �c c i wC 7 <br /> e4/ <br /> SITE STATUS <br /> i�tin' 7�iC ovsr>��.Lr Q � <br /> i <br /> EH 22 013 (Rev.4/91) <br />