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' AN .TOAQUIN COUNTY' <br />{ NOTIFICATION OF HAZARDOUS WASTE DISC <br /> HEALT'r-i & SAFM CODE 25180.7 '1 <br />'.A. EMERGENCY LEVEL: i II III QHS-EH:LOG <br /> ( clle One) <br /> E �I� <br />€ B. SOURCE OR INFORMATION phone: 2D S�Z-0`I4� <br /> Name: OrMA /-5u <br /> Com an : " <br /> I p y °�`�3S1 <br /> Address: Phone: (_ �) <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> i <br /> C. LOCATION AND DATE OF ISCGE <br /> Location: Jqr4maa (City r County) Circle One <br />�. (Best Physical Description) ,i <br /> Date of Discharge: !,crD �: <br /> Date Notified: , I Z�Z 7-,q Z;' Time: <br /> D. RESPONSIBLE PERSON USINESS r <br /> Name of Business: ijTelephone: <br /> Contact Person: <br /> Physical Address: li <br /> Mailing Address: .� <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: l <br /> ev <br /> Circumstances: <br /> I- <br /> F. ACTION TAKEN 4 r 6v`'� <br /> '1 li <br /> SITE DISPOSITION <br /> 5 a i it <br />` EH 22 013 (Rev-4/91) I �` <br />