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AN JOA UIN COUNTY <br /> S Q <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGEC(D Py <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:10II III PHS-EH LOG # / Z <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: (_) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: L� <br /> Reporting Agency Name: Sa.� Ty�.��„ �,rr�►'"�"-�^-� �oA <br /> Address: ZZ -7 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: &! b f �°- <br /> (Best Ph sical Descripti n) u (City o un Circle One <br /> Date of Discharge: <br /> Date Notified: 10- / ":g Time: /0do R71 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: C,z <br /> Contact Person: _/'� G mAm Telephone: (1 `14_-7ti 0 <br /> Physical Address: 456v A� _ - 0-5 3-3 <br /> Mailing Address: " <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: ( 1 - <br /> Chemicals: ow <br /> Circumstances . <br /> F. ACTION TAKEN -- <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />