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F t <br /> SAN ,TOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 0.7.., Gply <br /> A. EMERGENCY LEVEL:011rcle <br /> I III PHS-EH LOG # Wil/ <br /> ( One) <br /> B. SOURCE OF INFORMATION <br /> Name: Pow M e�cr�vr.�.2� Phone: (L ) V5-3- ws- <br /> Company: I ^ <br /> Address: o LdaLs <br /> Designated Employee Name: U Phone: �) <br /> Reporting.Agency Name: <br /> Address: f W? <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: //a c-e <br /> (Best Physical escription) it or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Z z 1 y' Time: Io:06 A •M <br /> D. RESPONSIBLE PERS�N/BUSINESS <br /> Name of Business: 9�na Ci+m <br /> Contact Person: Telephone: (� <br /> Physical Address: D e-t ' av-e.. <br /> Mailing Address: PS <br /> JOv <br /> E. DESCRIPTION <br /> Type of Discharge: Z <br /> Volume: iu• � <br /> Chemicals: r�nz au� - <br /> Circumstanc <br /> �- <br /> u <br /> F. ACTION TAKEN <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />