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.. SAN aroAQUV� COUNTY �� � COPY <br /> NOTIFICATION Off' HAZARDOUS WASTE DISC <br /> -HEALTH & SAFETY CODE 25180.7 <br /> A. 'EMERGENCY LEVEL-II III PHS-EH LOG h O3 - 3 3 <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name- t7 Yl n A-- KeA� Phone: q 5 1 7- ry9b() <br /> Company: <br /> Address: 5 K�►'� S � d �' <br /> Designated Employee Name: �f Phone:icil <br /> 2 •� <br /> Reporting Agency Name: t (" a57�0 Z <br /> Address: �• w�-v- lacy L: -C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) , { r County) Circle one <br /> ity <br /> Date of-Discharge, <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSONBUSINES-SL <br /> Name of Business: k P N1 <br /> Contact Person: 'l`G Phone: D . 5 7 z 3 <br /> Physical Address: 2u2S Ya0�d Co,v~PS C <br /> Mailing Address ] �O K �-�U <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: Tay <br /> Circumstances: <br /> F. ACTION TAKEN <br /> s <br /> SITE DISPOSITION___,kjdJA'- <br /> EH 22 013 (Rev.08/20/98) <br />