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aNly juAQUTAv C;UUNTY <br /> NOTIFI <br /> ON OF HAZARDOUS WAS - SCHARGE Q- <br /> lEALT1I & SAFETY CODE 251 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: —a rf(o� �, „ Telephone: ) e7e6 g-.-5wo <br /> Reporting Agency Name: <br /> r <br /> Agency Contact: C'�ar�ts rrtif Telephone: 2,9,7 ) /6k=3jyd <br /> Address: -qys N>, si,.• C'4 <br /> C. LOCATION AND DATE OF DISCPL4RGE <br /> Location: R �,f _&JT=,o <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: Time: 3' 9,5—/'M <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: c,�a Telephone: . -�r,►�� <br /> Physical Address: <br /> E. DESCRIPTION <br /> lWe Release: 76,k (7� <br /> e <br /> Volume: ..� !�`6-�i cM-ir <br /> Chemicals: <br /> r•. ACTION TAKEN <br /> rj C � c7 N <br /> ETI 22 013 (Rev. 02/90) <br />