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I <br /> UIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAIf I L C COPY <br /> HEALTH & SAFETY CODE 25180.7 _ <br /> A. EMERGENCY LEVEL: I) II III PHS-EH LOG TM a — C7oZ - <br /> (Circle one) <br /> B. SOURCE OF INFORiMATION <br /> Name:--&L& a u "`— Phone: ( ) <br /> Company: c� ' _ <br /> Address: q 3 7 -� � SF�e t e- �,- '' Z( 5-- <br /> Designated <br /> 5--Designated Employee Name: Phone: <br /> Reporting Agency Name: ;& ;f a&& <br /> Address: 6'-( <br /> C. LOCATION AND DATE OF DISCHARGE �( <br /> Location: LI �'1 <br /> (Best Physical Description) (City or County) Circle one <br /> Date of Discharge: <br /> Date Notified: , '�— Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Q(Jj �+Z; <br /> Contact Person: K`�i��ell Jk,n b� Phone: <br /> Physical Address: y o q o _ ��c�r `i S7� <br /> Mailing Address: 1Q U 0-jC a 1 A00 A !i E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: v� <br /> Chemicals:- u aSL "^ U <br /> Circumstances: <br /> F. ACTIO TAKEN ° <br /> -0-9110 n <br /> SITE DISPOSITION U 4tZ- GeAJ t ex, <br /> EH 22 013 (Rev. 08/20/98) <br />