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•AN JOA UIN COUNTY • FILECOP'S <br />S Q <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVE I I III <br />ircle one) <br />1 <br />C <br />C, <br />SOURCE OF INFORMATION <br />Name: 3) /// <br />Company: <br />Address: 7W <br />Designated Employee Name: <br />Reporting Agency Named?� <br />Address: tel) ee--, <br />PHS -EH LOG # <br />LOCATION AND DATE OF DISCHARGE <br />Location: J 0 % � 1. ,`1//?� <br />(Best Physicalescription) Ci County) Circle one <br />Date of Discharge: <br />Date Notified: Time: :�5? ' -3,4,o <br />RESPONSIBLE PERSON/BUSINESS <br />Name of Busine <br />Contact Person: <br />Physical Addre <br />Mailing Addres <br />E. DESCRIPTION <br />Type of <br />Volume: <br />Chemica <br />Circumsl <br />F. ACTION TAKEN :2a,-'-- <br />EH 22 013 (Rev. 08/20/98) <br />