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!VUTIJ"-'' AXION OF HAZARDOUS WAS"' DISCHARGE <br /> I-IEALTl-I & SAM" CO')L'.' 1 0.7 <br /> A. I m -Rc;F-NCY LIrVEL:CD II III PISS-EI-I LOG # <br /> (Circle One) <br /> B- SOURCE Or INFORMATION <br /> Original Source: %'Ct e Telephone: ( Dei ) 5Z //-X— <br /> Reporting Agency Name: 2j2ML,49,ac--kR"L6x&dj (J <br /> Agency Contact: Telephone: 0-0 9 ) D <br /> Address: �� 1-200 '7S7'�C-L4V>, ('14 9sa o r <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ' <br /> (Best Physical Desc ion) (City or County) <br /> Date of Discharge: <br /> Date Notified: Time: 3 nQ <br /> D. RESPONsmuz P - SON/I3 SWESS <br /> -� <br /> Name of Business <br /> Contact Person: Telephone: <br /> Physical Address: d <br /> E. DESCREMON <br /> ' Type Release: <br /> Volume: <br /> Chemicals: <br /> r. ACTION TAKEN <br /> r <br /> �' IFI 22 013 (Rev, 02 90) <br /> t <br /> (-\7) <br />