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' : SAN JOAOUIN COUNTY <br /> NOTIFICA'T'ION OF 117.ARDOUS WASTE DI�''1ARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> I II III PHS-EH LOG # <br /> EMERGENCY LEVEL (Circle One) <br /> SOURCE OF INFORMATION Telephone: <br /> Original Source' a <br /> t <br /> Reporting Agency Name. Tel ephone, <br /> Agency Contact: <br /> Address: // <br /> C LOCATION AND DATE OF DIS_ CHARGE/ S Gni <br /> Location: (City or County) <br /> =-- "-- <br /> (Best Physical Description) <br /> Date of Discharge: <br /> 5 , <br /> Date Notified: 10-2L c Time:�� <br /> J <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> �, j <br /> Name of Business 5� <br /> J Telephone: �+( 1 ) <br /> Contact Person: <br /> Physical Address: <br /> E, DESCRIPTION <br /> Type Release: <br /> Volume: <br /> u <br /> Chemicals: <br /> F. ACTION TAKEN S <br /> Q <br /> O <br /> I <br /> EH 22 013 (Rev. 02/90) <br />