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11. HAS A Prop 65 NOTIFICATION BEEN SENT BY ANOTHER AGENCY? 12. AGENCY THAT PROVIDED A Prop 65 NOTIFICATION: <br /> []YES ®NO <br /> (If"Yes" identify the agency in Box 12,if"No" proceed to Section III) (Skip to SECTION 111.4) <br /> SECTION III:DISCHARGE REPORTING <br /> 1. COUNTY HEALTH AGENCY: INITIAL CONTACT 2. COUNTY BOARD OF SUPERVISORS: INITIAL CONTACT <br /> DATE: ()!� DATE: glzg 1-0-13— <br /> TIME(MILITARY): — C rw_�( ( TIME(MILITARY): ( `• Z S Wvi+ I <br /> CONTACT METHOD: C�C"CAG. 1 CONTACT METHOD: Fk oo'C4-L w-c" I <br /> (Phone,Answering Machine,Conversation, Email) (Phone, w <br /> AnseAng Machine, Conversation, Email) /' <br /> CONTACT NAME: ,�C�(I ILGL►1L L- 11 S ate' v� s `��►i CONTACT NAME: VY1 (bit ( Wj,7 ZG`PHONE NUMBER W/AREACODE: z i� �G -. (� PHONE NUMBER W/AREA COI DE: ,(z(� 4(111 <br /> L%g 2 3S0 <br /> EMAIL: c��II5C'e-, =(re CL- �'��✓�'l EMAIL: Vv�CXI>���.�I� (L �J C�JJJp✓ <br /> 5S(ntL�(.� Cs7u.� <br /> WRITTEN NOTICE:This information may be supplied by the Proposition WRITTEN NOTICE:This information may be supplied by the Proposition <br /> lU12- <br /> 65 County Notification Unit. 65 County Notification Unit. <br /> DATE: ! / 6115 DATE: C�/moiZ -9 ;j7— <br /> POST <br /> 9 ;POST OFFICE CERTIFIED MAIL NUMBER: POST OFFICE CERTIFIED MAIL NUMBER: <br /> CONTACT NAME: 1C(�b�L �`l��e SSL / CONTACT NAME: +i�c 1 ✓�C'i-t K <br /> AGENCY: CC T� c( C_�uµTet � � I l AGENCY: SCitn t i �, I Y t1 L'T SL&.r VISOY`j <br /> ADDRESS: 1 �� L_ IF�`�L� �� ,�I ADDRESS: L4i4 Nortt\ <br /> CITY AND ZIP CODE: 5 + OC(,�� q.� ) (�S CITY AND ZIP COD 5vG� X952�� <br /> PHONE: UOG )L-{( —34 ZU '� PHONE: 12'�Aq <br /> EMAIL: 16 cV_- 'W C S CE( ,60 EMAIL: "L J Ui w S; �'� V •Ci r"� <br /> 3. STAFF CONTACT FOR FURTHER INFORMATION 4. DESIGNATED EMPLOYEE <br /> NAME: �I I( 13r,L (�( NAME: �EC �, MCC-/< S <br /> PHONE: (2((,.) 46,,L� —LfC.L Zr PHONE: <br /> EMAIL: jjr11 �lcLrW1:.� c�ci °rk) iC\ .c'Cc . �^�/ EMAIL: J / / -� <br /> REFERENCE FILE(e.g.permit#): L ( i'v C.�._. <br /> S. ADDITIONAL INCIDENT DESCRIPTION AND FOLLOW UP <br /> Signature of Designated Employee <br /> DATE SIGNED: <br /> TIME SIGNED: !s y p l C'u`°t� 1 <br /> U�Z�}IZD (A) ! T �7 <br /> 2/6/2015 <br />