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11. HAS A Prop 65 NOTIFICATION BEEN SENT BY ANOTHER AGENCY? OYES QNO (If "Yes" identify the agency in Box 12, if "No" proceed to Section III) SECTION 111: DISCHARGE REPORTING 12. AGENCY THAT PROVIDED A Prop 65 NOTIFICATION: (Skip to SECTION 111.4) AGENCY: CO0C4-1 ADDRESS: 4-14 CITY AND ZIP CODE: PHONE: EMAIL: Ckeisk- PftrcaTS 2o4r-ck 5-)pervm-lt.i S S1c., 57E (.9D-4 5 -roccron) c5-Do DATE: POST OFFICE CERTIFIED MAIL NUMBER: CONTACT NAME: 1. COUNTY HEALTH AGENCY: INITIAL CONTACT 2. COUNTY BOARD OF SUPERVISORS: INITIAL CONTACT DATE: TIME (MILITARY): CONTACT METHOD: (Phone, Answering Machine, Conversation, Email,) CONTACT NAME: I Co.11,-4 -1 PHONE NUMBER W/AREA CODE: vioct) „we _ ,-35c) EMAIL: twio_ S • -vaENG = j crc WRITTEN NOTICE: This information may be supplied by the Proposition 65 County Notification Unit. DATE: TIME (MILITARY): CONTACT METHOD: (Phone, Answering Machine, Conversation, Email) CONTACT CONTACT NAME: c-kicidr--,,D C.70.1-2-ck 1-11-44-•‘A\ ' PHONE NUMBER W/AREA CODE: 4 c-u 34 1\ EMAIL: za 5sc--14-NS . WRITTEN NOTICE: NOTICE: This information may be supplied by the Proposition 65 County Notification Unit. DATE: POST OFFICE CERTIFIED MAIL NUMBER: CONTACT NAME: AGENCY: bar,. ts) CO rs-4-1/41 ADDRESS: ;30?‘ 70Oct CITY AND ZIP CODE: k°5 -2-ol PHONE: EMAIL: 3. STAFF CONTACT FOR FURTHER INFORMATION NAME: r.c.ursra1/4<__ PHONE: (cisc.0 ctwat— 4..ktaao EMAIL: Mark_ Gcrf-c—Q_ bocIrd.S. Cci • ci 0 REFERENCE FILE (e.g. permit#)* 4. DESIGNATED EMPLOYEE NAME: 54-eu w.) PHONE: LCAci Lt(ek — Lko-E3 EMAIL: -Y1-eue..) . cx‘ee-4Q 1..A3 ccks-boa rid ce, , Signature of Designated Employee DATE SIGNED: TIME SIGNED: 2/6/2015 5. ADDITIONAL INCIDENT DESCRIPTION AND FOLLOW UP