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~, 10/117/;013` 11:31 2094683433 SJC EHD UNIT 3 PAGE 02/03 <br /> NW ..W <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT& PHONE NUMBER <br /> N p tJ N e1 l� G �tv CaJ �2' <br /> INCIDENT MO n DAY YR TIME ' OES <br /> DATE 7' Z 113 OES /y pr (rse29hrtime) CONIROLNO. 1311]3 1 qj <br /> I <br /> INCIDENT ADDRESS LOCATION CITYICOMMUNITYCOUNTY ZIP <br /> ?a kS Rr"G arl�� /���ra'D aA� So �Ja <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number seemy��s <br /> Ase r fNj'Xf "e <br /> CHECK IF CHEMICAL IS LISTED IN CHECKIFRELFASEREQUIRESNOTIFI- <br /> 40 CFR 355, APPENDIX A CATION UNDER 42 U.S.C. Section 9603(a) <br /> PHYSICAL STATE CONTAINED— PHYSICAL. STAU RELEASED 0 QtIANTITY RELEAI, <br /> ❑ SOLID 5QLIQUID GAS I OSOLID WLIQUID ❑ GAS ����® <br /> L_jjENVIRONMENTALCONTAMINATION TIMEOFRELEASE DURATION OF RELEASE <br /> ❑AIR ❑WATER ❑GROUND❑OTHER Z y;3©/.�� _pgy8_HOURS=MINU <br /> ACTIONS TAKEN nr /�o Q ` /11 'P/15or,be /7 !absorb T rJ[ e11 <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS (Use the comments section Por addition Information) <br /> ❑ ACUTE OR IMMEDIATE (explain) iM <br /> ❑ CHRONIC OR DELAYED(explain) <br /> ❑ NOTKNOWN (explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> COMMENTS (INDICATE SECTION (A-G)AND ITEM WITH COMMENTS ORADDITIONAL INFORMATION) <br /> CERTIFICATION: I comfy under penalty of law that I have personally examined and I am familiar with the information <br /> submitted and believe the submitted Information Is trio, 90drrate, nd mmp t0, 6'm4 <br /> '' / � �� <br /> REPORTING FACILITY REPRESENTATIVE (print or type) Uy L-Q <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE TE: <br /> RECEIVED <br /> OCT 21 2013 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />