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NOTIFICATION OF HAZARDOUS WASTE DISCI-TARGE <br /> IEALTI-I & SAFETY CODE 1 7 <br /> A. EMERGENCY LEVEL u III PHS-EH LOG # Ga <br /> (Circle: One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: jV<��}?� t 4 � -k lr(`/�igGcL Telephone: <br /> Reporting Agency Name: Sir .�o�� =i� ,��� �G{ <G cUvUCf��r , /v. <br /> Agency Contact: i%� % , l,` �r�,-`� Telephone: o�D <br /> Address: 1 • � � PhC �D 9� Q�1�4� �� -�o� O/ <br /> C. LOCATION AND DATE OF DISCI-LARGE <br /> Location: t l D l #Tlf <br /> (Best Physical Descriptio (City or County) <br /> Date of Discharge: <br /> Date Notified: C;/ / Time: <br /> D. RESPONSIBLE PE ON/BUSINESS _ <br /> Name of Business <br /> Contact Person: �I,fCIiYLUt( ���(', Telephone: (P1)����" <br /> Physical Address: n) �Va,2 - ice[ Q , � '�/'LD, �/� 9-�7, / <br /> E. DESCI=ION <br /> Type Release: /a�yl QrCc n�•hC� �i <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br /> L 4-71 t Sr? <br /> -per <br /> EH 2 013 (Rev. 02/6) <br />