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CopySAN HAZARD COUNTYNOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 0II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION L <br /> Name: Phone: <br /> Company: / <br /> Address: L°i9 <br /> Designated Employee Name: S Phone: t/6�l 3tlsi <br /> Reporting Agency Name: n <br /> Address: eSy. Gs9 C. LOCATION AND DATE OF DIS� / <br /> Location: ffirit><� <br /> (Best Physical Des nption) (�r County) Circle One <br /> Date of Discharge: 1,,y7 44Ltr7i. <br /> Date Notified: t/11"14V Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: �L� ortljo <br /> Contact Person: © Telephone: �9) <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION n <br /> Type of Discharge/: /I17ru�iiir✓/ / /IQ�CtdC. <br /> Volume: Aizyii&;r- , <br /> Chemicals: �o <br /> Circumstances: l / <br /> flS7'/wwz <br /> F. ACTION TARN <br /> SITE STATUS <br /> EH 22 013 (Rev-4/91) <br />