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Di <br /> I <br /> Office of Emergency ServicesAIN I I KM <br /> pp <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FOR UIN COUNTYOFFICE OF EMSAN JOAERGENCYSERPICES <br /> BUSINESS NAME I FACILITY EMERGENCY CONTACT d PHONE NLTSBER <br /> A L )eSfe✓nJ tz(rnn Sef�T l)c Tad Sfeve C ( eIKF.,I;t�(L`I) St47—Z60o <br /> INCIDENT MO DAY YR .'.:I <br /> MeCIES <br /> DATE Z17 NOTIFIED (u1e 24 hr ti.) <br /> CONTROL NO (�/ p)1 j <br /> C ev, QJCIDF.NI C77Y///COA94UNITY COUNTY ZIP <br /> f- fir/J J /✓. C3.Oce-[t/:.<..:r - 5 7`iJ c_r�!✓.tiJ ,�. <br /> y CH�ElM� ICAL OR TRADE NAME(pr m or tyyc : CAS Nuaobtc <br /> 1/— <br /> ": CHEM IF CHEMICAL LS LISTED IN CHECK IF RELEASE ASE REQUIRFS,NOTIFICATION <br /> 40 CPR 375,APPENDIX A UNDER 42 US.C.f 9603(0 <br /> D <br /> EdPHYSICAL STATE CONTAINEDPHYSICAL TE RELEASED QUANTITY RELEASED <br /> L7_ XXm XLIQUID CI GAS I El SOLID ZLIQU D C GAS /<.P41 90 (-'?/S /)f'ufe <br /> OMMONMEMIAL IN <br /> COTAAHNX11ON 0 TD.tE OF RELEASE IM DURA'T}pN OF RELEASE <br /> J ❑ AA GD MATER { (IROUND EI OTHER 02;3U-Of,r DAYS HOURS—25-' 4@4JITES <br /> ACTIONS TAKEN <br /> Q/S 'J�i2 CerN/ e .iX /GL::r '.v ' rawC G to C�,ve'Y.rf' G:v1rr.Ctr 1 R�� <br /> b� �Lrt clee -I,ew (2 f. r3 b 5�c e cir/rLe F ' <br /> �Au �d � o f r Lz d=L s`/ab3�: <..�_'c/l if / Il4 S u• I G ClrJ n <br /> /�Jv �l/flet ELL LIf�S Ttup ),� / rhfC7i CU.4.t IS�i^:vr✓ r2 TOrm l.Q ��t b�lL /'f`r+e:�/P• <br /> ISeyvices oicl~avd d Lk Ac6 <br /> =40"OR ANTIC.?ATI D HEALTH TH EFFECT'S Nr 69 mar asum fair viol idasetsl <br /> ACLTE OR D.Q4�IATE(saglr) t1c�u. i 1 •al L;;,,ed, i nbsu: rc 4 t <br /> F e.A,�s S.r bSF'...,ilaf 13..�t T,.ti�l�:s^f .i�< 5..�K.y, C'c:LLL Sicl�.}iz¢i}ari.. <br /> j CHRONIC OR DELAYED(.*M) <br /> ❑ NDT RNOSYN(.rah.) <br /> ADVICE REGARDLNG MEDICAL AT7EIMON NECESSARY FOR E(POSED INDIVIDUALS <br /> p I <br /> G I ! moi. T L Q it l Is ri�cr-e�. <br /> COMMENTS INDICATE SECTION tA-G)A.ND ITEM RTIH CO&Qv(ZN.TS OR ADDITIONAL INFORMATION <br /> j '�h�rsr� �L :�, `I � �t! /�,�p-� x O93o yLr �Gael K `r� c�r;rled <fel;eCl<�.z.k.ts <br /> H � Orc ( arlOej`0 OOLdd b%e 114&de L'� S (ZO"/(/ 1AM4 <br /> I <br /> Iffffl �k•f, Cn' l� tl. v .w�"- S�L � f� �rZScvbp...'>/iL'rc.5 .Ccr-�6a/� J�LaE� rF.v,:, rc»��»�,i" <br /> (a, ci,ve "_4 PLcKay eek. (-77'-:FS (,,L, fJrur 51 cr_K'c/ .J,_e ll�d <br /> CERTIFICA'^ION: I by ccrufy Lode,petmlty of lav that I have pen ally exam rm d and 1 am lamiliar wah the <br /> aafmnauon wLbauoed amd believe the submn,,j mfwma4on is <br /> ILITY ttL<. .am k c. <br /> I REPORTING FACREPRESENTATIVE(Mm[orrype) eLt 'kI Pn-t P�tJ <br /> SIGNATLREOFREPORTING FACL=REPRESE'NTATI * DATE <br />