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SAN ,FOAQ UIN COUNTYAL <br /> i <br /> NOTIFICATION OF HAZARDOUS WASTE D[SCHARGE a y; ~ • <br /> HEALTH & SAFETY CODE 25180.7 <br /> Aa EMERGENCY LEVEL: I II IIi PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: PAHA L A- Phone: ,o ff r�`; vYZa <br /> Company: v a <br /> Address: s o ? /> T7 J <br /> Designated Employee Name: Phone: ,Q ) � y <br /> Reporting Agency Name: ✓ <br /> Address• <br /> C. LOCATION AND DATE OF <br /> • _ ,D[SC'riARGE <br /> Locarion &je, Iv r r'6 <br /> •(Best Physical Description) <br /> .J -Y— (City or C�ro ) Circle One" <br /> Date of Discharge: i <br /> Date Notified: T roie• 8"! a v <br /> D. RESPONSIBLE PERSON/BUSINESS - t <br /> Name of Business: <br /> Contact Person: - Telephone: <br /> Physical Address: Z V ` .I. <br /> Mailing Address: 4. jw <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> a <br /> Voolumew:f_ Il,✓�ch,v-,,r� LL <br /> Chemicals: GWti^^^ y.o C/14 9 !JS O w kc l GIvTY�� <br /> Circumstances: �' ✓ Ropy ►^ <br /> j <br /> F. ACTION TAKEN — " w <br /> d <br /> ;m <br /> SITE DISPOSITION TT <br /> a. a <br /> „ <br /> EH 22 013 (Rev-4/9I) <br />