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,' q O <br /> _ 9 <br /> -... <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG �� <br /> ( c1e One) <br /> 3. SOURCE OF INFOR�A ION <br /> Name: <br /> Phone: 4�) OROD <br /> Company: 17n C, <br /> Address: q 5:5 SJ <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 25 Y • ��� t <br /> 2 X3 ' <br /> faC <br /> (fest Physical Description) �r County) Circle One <br /> Date of Discharge: UM C-vM <br /> Date Notified: Time: <br /> D. RESPONSIBLE P£RSOBUSINESS ^ <br /> Name of Business-. V\vex-�,Lae, k OD ' <br /> Contact Person: M I KP, 1 Y-15 Telephone: <br /> Physical Address: <br /> Mailing Address: 159Oro 41 rAeb <br /> E. DESCRIPTION <br /> Type of Discharge: fa <br /> Volume: t LAKrx� - <br /> Chemicals• <br /> Circumstances: kev� <br /> 1 1Gq- cif nnn 6v4-- <br /> F. <br /> v..(1 -F. ACTION TAKEN <br /> SITE DISPOSITION LU III <br /> s bye_ . <br /> r <br /> ('scP ) <br /> X <br /> Ft; 172 nil (Re-v.4191) <br />