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D <br /> O CO TY <br /> DOUS WAST <br /> NO'TIF'ICATION OF HA SAFETY CODE 25180.7 <br /> SC��,RGE <br /> HEALTH <br /> LTH <br /> PHS-EH LOG� <br /> A. EMERGENCY LEVEL: I II III <br /> `(,ircle one) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: <br /> .(�� <br /> Company: nJ 1 r <br /> " v ,�� <br /> Address: c7 Phone: <br /> Designated Emplovee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: N� �,{, 2c c or <br /> (Best Physical Description (City or County) Circle one <br /> Date of Discharge: l�� `d 1-1 <br /> `I Time: <br /> Date Notified: `{ a <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: r - Phone: <br /> Contact Person: •,q� cam• <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: •c. )L—,,. <br /> Chemicals: ! z i /a— <br /> ces: L 2� a= I` !�o <br /> vc <br /> Circumstances: <br /> (,�;,�_rC 1 f- l� O^J �11 t—i J�-��i L G 1'�- .-•- n <br /> F ACTION TAKEN <br /> SITE DISPOSITION <br /> EH 22 0l3 (Rev. 08/20/93) <br />