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NOTIF►CATION OF HAZARDOUS WASTr DISCI-TARGE <br /> HEAL;n-i & SAFE'T'Y CODL' .�80.7 <br /> A. EMERGENCY LEVEL:(9 LI III # <br /> Q _ J <br /> S-EI3 I,OG =- <br /> (Circle One) <br /> B. SOURCE OF INFORMATION } <br /> Original Source: l,4 e1�j/ / Telephone: a0 �1v��3905 <br /> Reporting Agency Name: _QQ_4,7 rC f7/S�S <br /> Agency Contact: � ��,,/�� �� Telephone: <br /> Address: A- a00 q .S71,?�C� O / <br /> C. LOCATION AND DATE OF DISCI-LARGE <br /> Location: J&57 3AA / - S_/-Z)C 0M-L./ <br /> (Best Physical Des ription) (City or County) <br /> Date of Discharge: <br /> Date Notified: a Time: J l• 3614pl, <br /> D. RESPONSIBLE P - SON USLNESS <br /> Name of Business <br /> Contact Person: Telephone: o� gyp' �77a <br /> Physical Address: <br /> E. DESCRWTION <br /> Type Release: <br /> Volume: ,a <br /> Chemicals: -' <br /> F. ACTION TAKEN <br /> 49 <br /> r <br /> LII 22 013 (Rev. 02/90) <br />