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NOTIFICATION OF HAZARDOUS WASTE ) CHARGECO[Py <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:0II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company:�1<<.aMP3F�� <br /> Address: 1 to 2 _ Av6 . Gov7jf, r-p- raw ec-o e4- gyy� <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: G�al- <br /> (Best Physical Descriptio ity rir County) Circle One <br /> Date of Discharge: 164/, 1 <br /> Date Notified: /a/y�� Time: <br /> D. RESPONSIBLE PERSON/BUSINES <br /> Name of Business: 1���J /oJ •4n e_ed <br /> Contact Person: '77/f-7 - — Telephone: »3-5, 2�>W <br /> Physical Address: / ow je / oD i c4 '-A <br /> Mailing Address: /-,/l/v zz o/ !24 -7t� p <br /> E. DESCRIPTION <br /> Type of Discharge: . <br /> Volume: "'?, <br /> Chemicals: <br /> Circumstances: i ��'i,U ,r <br /> � 1 <br /> F. ACTION TAKEN l✓� !l <br /> -T i4i5' A�cr,� pt <br /> "°O o3 3/191 <br /> r <br /> SITE STATUSr- <br /> G .� 7- r3,67 <br /> EH 22 013 (Rev.4/91) <br />