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0 <br />TIN <br />COUNTY <br />NOTICTION OF HAZARDOUS <br />JOAQOUS WASTE DISCHARC <br />HEALTH & SAFETY CODE 25180.7 a D <br />EMERGENCY LEVEL: ® II III <br />(Circle One) <br />SOURCE OF INFORMATION <br />Name:r"1rzY <br />Company: o. 0.s <br />Phone: �� y�•- 3�� <br />Designated Employee Name: Phone: (_) <br />Reporting Agency Name: <br />Address: 5av/ Ave: <br />C. LOCATION AND DATE OF DISCHARG <br />Location: Z35 �r <br />(Best Physical Description) r County) Circle One <br />Date of Discharge: <br />Date Notified: _gf i 5,1� 5' Time: ^ R �•g•.-, <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: ?A! --c recln4: <br />Contact Person: Telephone: 3 5Y -44v/ <br />Physical Address: 636' g. ,�-rts•. s :�e v-- �, �- !E4 may- zdo <br />Mailing Address: _ P.o. a2o2C /.g-9 2:2 7.,l D! A-!) <br />E. DESCRIPTION <br />FS <br />Type of Discharge: <br />Volume: ^ /a r<o., <br />Chemicals: <br />Circumstances: Ails 91A cu4,5. 7n,:::.eA /As o..E.s <br />EH 22 013 (Rev.4/91) <br />