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3,-a4 JUAQU.Ui C:OUNT11 <br /> NOT, `ATION OF 1IAGARDOUS WA... . DISCHA.RGE <br /> I-1 ALTli & SAF M- CODE 25180.7 <br /> A. EMERGENCY LEVELII III PHS-EH LOG # <br /> (Circle One) UI j <br /> B. SOURCE OF INFORMATION <br /> Original Source: /� , /�,p�✓C1�� Telephone: 46-�, - 3,4 2-1 <br /> Reporting Agency Name: <br /> Agency Contact: Telephone: <br /> Address: AJ -`MVV 7 4vrn( <br /> C. LOCATION AND DATE OF DISCILARGE <br /> Location: �zlZ- Al- ASN Oct)- <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: �-Zl�lKNV UI�(l <br /> Date Notified: , qa Time: - q ,!L <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: Telephone: -;-4 <br /> Physical Address: 42- A/ <br /> E. DESCRE'TION <br /> Type Release: <br /> Volume: _ 6"'N k1JDU,1 f ►= ,, <br /> Chemicals: <br /> F. ACTION TAKEN <br /> -- 64-)[)R ,t/cI SniL <br /> Ofir. �dM i N/I`Tl%=�1 �S ��� �li��]� �F' 'T��F �C ,'�f•}C'/�"�, <br /> J�, EII 22 013 (Rev. 02/90) <br />