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SAN JOA <br /> QUIN COUNTY 0 <br /> NOTIFICATION OF HAZARDOUS WAS'T'E DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL • R III <br /> PHS-EH LOG � <br /> e One) <br /> B. SOURCE OF INFORMA ON , <br /> Name: /e Phone: <br /> Company: chzkW2 <br /> Address: Pa. L5& (a 6 a ex Tk7=d - gp <br /> Designated Employee Name: phone: �- <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DIS G 1 <br /> Location: 44-1019 e w,�d ✓2� /.�7� <br /> (Best Physical Description) (City or Circle One <br /> Date of Discharge: <br /> Date Notified: 3 2 Tune• /'®o,pYn-- <br /> D. RESPONSIBLE PERSON SINESS <br /> Name of Business: �6cfl�cl <br /> Contact Person:' ® &142 Telephone: 6P-r— <br /> Physical Address: <br /> Mailing Address: 6 ao y 3-C3 <br /> DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> . . ACTION TAKEN_ UI�11' <br /> SITE DISPOSITION /r y <br /> , <br /> E : 22 013 (Rev.4/91) <br />