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NOTIFIr,kTION OF 11ALAY2.DOUS WA.q`r"" DISCI-TARGE <br /> ( 1-IEAL`I'1-I & SAFL--ry COD L21" _ ..J:1 <br /> A. EMERGENCY LEVELO II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: f�,�=�- Telephoner <br /> Co / <br /> Reporting Agency Name: f N <br /> Agency Contact: l Telephone: ( DSI ) Lf� <br /> Address: &4 a 0 O 5-Q O / <br /> C. LOCATION AND DATE OF DISCI-I.ARCD <br /> Location: L?D 7 S, W,'1 kN,, / � � ����✓t <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: "I <br /> Date Notified: //9n Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business n <br /> Contact Person: Telephone: <br /> Physical Address: <br /> E. DESCRIPTION 5 �-o G I C 0 v l <br /> 1I pe Release: <br /> Volume: d7-� -- <br /> Chemicals: _=S,�x.e-u fieri, ate► a �t-tn�U�,,, <br /> F. ACTION TAKEN <br /> r <br /> lir <br /> EI-1'22 013 ( ev. 02/90) <br />