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JAN J UAQ U LN UU UN 1 Y <br />NOTIFIC"TION OF 1Lk'LAYtDOUS WASTE ^ISCI-LARGE <br />IEALTI-I & SAFETY CODE 2S1 7 <br />A. EMERGENCY LEVEL: &I III PHS -EH LOG # 9/- <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />Original Source: Telephone: (� 83 5 3 <br />Reporting Agency Name: <br />Agency Contact: Telephone:3 Y3 �1 <br />Address: <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: 1%1/ S40,4 L056LDAz- <br />�tesdP sical Descrip '6n) (City oroun <br />Date of Discharge: <br />Date Notified: - �- �'/ / Time: <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business <br />Contact Person: "l Telephone:ac o9) <br />Physical Address: - a.0 SD 0 LL-2zd T 2z -t4 , C' a9 q6-37 <br />E. DESCRIPTION <br />Type Rel <br />Volume: <br />Chemicals: # <br />F. CTIO TAFgf-Z',� <br />C-) - „ Owe <br />N <br />s <br />70 <br />EH 22 013 (Rev. 02/90) <br />