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SAN JOP,QULr COUNTY <br /> HAZARDOUS WASTE DISCEL <br /> NOTIFICATION OF H�,ZA 41LE COPY <br /> HEALTH & SAFETY CODE 25180.1 <br /> A. EMERGENCY LEVEL' I II III <br /> PHS-EH LOG <br /> ( irele one) <br /> B. SOURCE OF NFOP-MATION <br /> Name: LYi�i�i�z' i" i (3 Ct✓ Phone: ( ) <br /> Company: <br /> Address: - Phone: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHkRGE <br /> Location: 1630 A —S 0C <br /> (Best Physical gescnption) i itv ,) ounr, ircle one <br /> Date of Discharge: <br /> Date Notified: = y <br /> D. RESPONSIBLE PERSONBGSINESS <br /> Name of Business: Phone: <br /> Contact Person: <br /> Physical Address: r t <br /> ✓failing Address:_6 Aw C <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: _ <br /> Circumstances: ^ '� <br /> R <br /> F. AC ION T. KFIN <br /> J <br /> .t <br /> SITE DISPOSITION <br /> y <br /> EH 22 013 (Rev. 08/30/93) <br />