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w..i SA`i J0AQULy COL`�+Ty <br /> yOT1FICATION OF HAZARDOUS WASTE DISCELAfILE COPY <br /> HEALTH & SAFETY CODE 25180.7 <br /> ' 11 PHS-EH LOG T 01 <br /> A. EMERGENCY I ircle one) <br /> { <br /> B. SOURCE OF NFOR_1r1ATION <br /> // <br /> Marne: __�� Phone: ( ) <br /> ( C1i CZs <br /> Companv. <br /> Address: Phone: <br /> Designated Emplovee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCRARGE <br /> Location: I63D - c In .� ount� ircle one <br /> (Best Physical eseripcion) <br /> Date of Discharge: <br /> Date Notified:— <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> dame of Business: � <br /> Phone: <br /> Contact Person: <br /> Ph,'sica.l Address: <br /> Mailing Address: 6ttlE <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> V olume: <br /> Chemicals: <br /> Circumstances: f r <br /> F. AC ION T. Y <br /> SITE DISPOSMON <br /> > > <br /> EH 22 (Ret. 03120193) <br />