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�li T J, <br /> SAN 30AgUIN COUNTY <br /> NOTIFICATION OF HAZARDpUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> I <br /> # 9 <br /> � - <br /> IIII PHS-EH LOG <br /> A. EMERGENCY LEVEL:(I E <br /> (Circle One) ' <br /> L <br /> B. SOURCE OF INFOFI MATION !n <br /> Phone: <br /> Name: <br /> Company: <br /> P <br /> Address: o J ✓r. <br /> Designated Employee Name: FI Phone: <br /> Reporting Agenc Name: <br /> Address: C 5 dQ <br /> 1 `I <br /> C. LOCATION ANDTE OF DISCHARGE <br /> Location. /� D / Gor •�'� • (City or oun Circle One <br /> (Best Physical Description) a <br /> Date of Discharge: Dw <br /> Date Notified: �; <br /> Time: : oa <br /> D. RESPONSIBLE PERSON/BUSINESS �1 ��UG�. <br /> Name of Business. G4 Telephone:: 7,7" <br /> Contact Person: <br /> Physical Address: �. <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: eco f <br /> Chemicals: '' — <br /> Circumstances: .Q ^�� w G - e4Arova¢L <br /> F. ACTION TAKEN `^ <br /> e <br /> SITE DISPOSITION <br /> -773 <br /> EH 22 013 (Rev-4/91) ' <br />