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&OPOSITION 65 DISCHARGE REPOR-A <br /> File Number: <br /> 1. - Date of Report: j'7q I 2. Discharge Date: <br /> Mo Day Yr[� Mo Day Yr <br /> 3. Reported By: �ame-g R, pinet$Go <br /> Name of Designated Employee <br /> TSCD: HQ NCS NCS-F NCCS SCS <br /> Environmental Health nn Health Protection <br /> Branch or Section: S I�Q. 1 1 11f IdQf IOV< <br /> 4. Discharge Location: nn II ,, <br /> Name: �ehhae dlS�rt4tJ�loH Re41oK Des+ - TrtACK S1?e <br /> ,( 5sa7S - <br /> Address: AS�IUo Coo+h ehMSh1CLN Iia! TQACKF CA 92000/ 486)JOAQQJAD <br /> Street/P.O. Box City Zip Code COUNTY <br /> 5. Discharee Tvpe: Spill Tank Leak Vapor/Fume _ Unknown <br /> WDR* NPDES* Other <br /> 6. Information Obtained Bv: Phone Report Letter <br /> Inspection _ Emergency Other <br /> 7. Person Reporting: <br /> Name: 4" tWA{. C 1.000 <br /> Address: JArna AS !rWd FACILITY <br /> Street/P.O. Box City Zip Code <br /> Telephone: ('LM) 537.' g1QS <br /> 8. Description of Discharge: (,Ust chemicals as confirmed or suspected; <br /> concentration levels; volume or mass; and any other narrative details. ) <br /> url. a.� 4 ;%,L Lci ( tkies group%d w4;,4d.+^ ec1 <br /> b a-ck up o oo LwF'e&AW e,s,ti�yM.:ne.,4a.R. wa.�ar ?He oow aaLkS <br /> oQ TCL Ae8 a.� C,&^a ,I%A-^4-+t .tib 0 � LtS PP10 <br /> 9. Initial County Notification: SAN -10ACIVW (Jo. D��i�e. off` 10�15�4 <br /> Designated Contact: �_ �w'�r1t~C� SeUUICCS Date/Time: Apppof. 10:ZpAm <br /> Yes No Name <br /> Other _ <br /> Contact: (_) Date/Time: <br /> Name Telephone <br /> *WDR: Waste Discharge Requirement <br /> *NPDES: National Pollutant Discharge Elimination System <br />