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STATE WATER RESOURCES CONTROL BOARD NOTIFICATION Form TO COUNTIES OF HAZARDOUS WASTE DISCHARGE <br /> SAFE DRINKING WATER AND TOXIC ENFORCEMENT ACT OF 1968,PROPOSTION 65 <br /> SECTION 1:PRELIMINARY NOTIFICATION DECISION <br /> 1. DOES THE DISCHARGE MEET ALL FIVE OF THE PREREQUISITES? 2. DATE: c'� 2(� ��,j �3. TIME: L�7 ��. /S'; <br /> 19YES ❑NO © 1 <br /> 4. STATE OR REGIONAL BOARD OFFICE: 5. PROGRAM (e.g. UST, DoD, NPDES, other): <br /> C <br /> r Ile ° .o 5 -s c`c rat,,,e"ti i t tc G tea t A (./ t <br /> SECTION II:DISCHARGE INFORMATION <br /> 1. DATE OF DISCHAR : 2. DISCHARGE TYPE: r <br /> fi( o' v U <br /> 3. HOW DISCHARGE DIS COVERED: / <br /> L�JL i� ��1 - e.� ' A-,<,; <br /> Ste ' y' to <br /> 4. REPORTING SOURCE <br /> !} r 1 5. PROBABLE DISCHARGER [� _ <br /> NAME: �t�ln�E1v 4=cG:�v�lr.,ct nl �I NAME: 6�1�I��Ir �+'��f" I�ro �- —•CGc�rL ��-7t,M&S 140-fir 1,� <br /> STREET ADDRESS: S lncu J U e(J�z v1�r u STREET ADDRESS: <br /> CITY/STAT /ZIP, ODE: 's t0Cl:{,v. CA CITY/STATE/ZIP CODE: <br /> EMAIL: ����Cl�1l�C VCi C�y `''��;�.cJW� EMAIL: 54vw C?S 0NOY*roo e rt5 4,kw AA <br /> PHONE: _ G L� PHONE: ����(� t . ?Z <br /> 6. DISCHARGE LOCATION /I � /� 7. DESCRIPTION OF DISCHARGE INCIDENT: / <br /> NAME: 3Yt^�Gi/ �i LG�1t�1C�1/ — /�/`l�Ic y Trostf`),v.' 0 tJcEL- <br /> ADDRESS: V�- <br /> CITY/COUNTY/STATE/ZIP CODE: Stoc6C�ott/ sx./C'q�`752u <br /> PHONE: .,z <br /> GIS LOCATION: Latitude Longitude <br /> MONITORING INFORMATION <br /> 8. CHEMICAL NAME 9. VOLUME, M SS AND UNITS OF THE CHEMICAL 10. MEDIA TYPE(AIR,WATER,SOIL) <br /> 1 The discharge incident must meet all five of the prerequisite listed in the instruction sheet. If all five prerequisites are met,this starts the 72 hour county <br /> notification clock. See instructions for more information. <br /> 2/6/2015 <br />