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AXPa <br /> 1 AQ ' COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> . HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELI II III PHS-EH LOG Fy- <br /> ircle one) <br /> B. SOURCE OF INFORiNIATION <br /> Name: 1Gh�' gL11� Phone: (qua) "3(a1-0Lf00 <br /> Company_: I n-t'err'►a e <br /> Address: <br /> Designated Employee e: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 72--�1oC} 10Cxca,�� <br /> (Best Physical Description) ity aunty) Circle one <br /> Date of Discharge:__51 - 0 -- -- - <br /> Date Notified: Time: 3'•y� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: fah 17� l 2 rnt� Phone: <br /> Physical Address: <br /> Mailing Address: TO goc "a-1 l i>G I la <br /> E. DESCRIPTION <br /> Type of Discharge: v nro a• � r'�- <br /> Volume: ini�h v,N1 <br /> Chemicals: _ <br /> Circumstances: 1 <br /> F. ACTION TAKEN _ <br /> SITE DISPOSTTION <br /> EH 22 013 (Rev.08/20/98) <br />