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j <br /> 00 SAS JOAQLLr COL-QTY V FILE COPY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG T <br /> (Circle one) <br /> B. SOURCE OF NFOR..IATION <br /> Name: Phone: ( ) <br /> Company: <br /> Address: C- <br /> Designated Employee Name: �eJ �`�'i`�t� B Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCI-LARGE <br /> Location: ��J �� 5 I .Qa22 �S��C�I 1 <br /> (Best Physical Description) Cr`Count<) Circle one <br /> iti` <br /> Date of Discharge: <br /> Date Notified:_ / = f% Time: -��nyv✓ <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: ' ' SLI` Phone: <br /> Ph,.-sical Address: <br /> LN/tailing Address: G , — <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: n �t-v`►'�� <br /> Chemicals: <br /> Circumstances: <br /> a4 <br /> F. ACION TAKEN ' <br /> SITE DISPOS ON ' <br /> �r <br /> EH 22 013 (Rey. 08/20/98) <br />