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'ee'' SAN J0AQULr LOW TEDISC.ARFIL E COPY <br /> NOTIFICATION OF aAZARDO <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL91i, II III PHS-EH LOG <br /> irele one) <br /> B. SOURCE OF INFOFNI?.TION <br /> Name: LFii �� [� �r'i G Phone: <br /> Company. <br /> Address: <br /> Designated Employee dame: Gv Phone: d?d <br /> Reporting Agency Mame: <br /> Address: <br /> C. LOCATION AND DATE OF DISCI -kRGE l_ <br /> Location: „�. .�� v , <br /> (Best Physical <br /> Description) (City or County) Circle one <br /> Date of Discharge: <br /> Time: <br /> Date Notified: % <br /> D. RESPONSIBLE PERSONIBC;SNESS <br /> dame of Business:s <br /> Contact Person: Phone: - " <br /> Physical .address: � �-'✓- � <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: !/LAR lZ <br /> Volume: <br /> Chemicals: C�eea <br /> C i rc ums"t?a�nj�ces: <br /> F. ACTION T.kKEN <br /> _ S _ L <br /> a � <br /> SI7 DISPOSITION <br /> �1 <br /> EH 22 013 (Rev.03/20/98) <br />