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`, ltl/1,Y/Ltl13? 11:31 2094683433 SJC EHD UNIT 3 PAGE 03/03 EMERGENCY RELEASE FOLLOW-UP NOTICE RECEIVED REPORTING FORM INSTRUCTIONS (This forth may be reproduced,as needed) 0 C r 2 I 2013 GENERAL INFORMA'T'ION: Chapter 6.95 of Division 20 of the California Health and Safety Code requires that written emergen prepared pursuant to 42 U.S.C. § 11004,be submitted using this reporting form.Non-permitted releaseMegqmunt Extremely Hazardous Substances(listed in 40 CFR 355,appendix A)or of chemicals that require release rport 103(a)of the Comprehensive Environmental Response,Compensation,and Liability Act of 1980[42 U.S.C. §9603(a)]must be reported on the form,as soon as practicable,but no later than 30 days,following a release. The written follow-up report is required in addition to the verbal notification BASIC INSTRUCTIONS: • The form,when filled out,reports follow-up information required by 42 U.S.0§ 11004. Ensure that all information requested by the form is provided as completely as possible. • If the incident involves reportable releases of more than one chemical,prepare one report form for each chemical released. • If the incident involves a series of separate releases of chemical(s)at different times,the releases should be reported on separate reporting forms. SPECIFIC INSTRUCTIONS: Block A:Enter the name of the business and the name and phone number of a contact person who can provide detailed facility information contenting the rclume. Block B:Enter the date of the incident and the time that verbal notification was made to OES.The OES control number is provided to the caller by OES at the time verbal notification is made.Enter this control number in the space provided. Block C:Provide information pertaining to the location where the release occurred.Include the street address,the city or community,the county and the zip code. Block D:Provide information concerning the specific chemical that was released.include the chemical or trade name and the Chemical Abstract Service(CAS)number.Check 4 categories that apply.Provide best available information on quantity,time and durdtiun of the release. Block E:Indicate all actions taken to respond to and contain the release as specified in 42 U.S.C.§ I I004(c). Block P:Check the categories that apply to the health effects that occurred or could result from the release.Provide an explanation or description of the effects in the space provided.Use Block H for additional comments/information if necessary to meet requirements specified in 42 U.S.C.§ 11004(c). Block G: Include information on the type of medical attention required for exposure to the chemical released.Indicate when and how this information was made available to individuals exposed and to medical personnel,if appropriate for the incident,as specified in 42 U.S.C.§ I1004(c). Block H:List any additional pertinent information. Block 1:Print or type the name of the facility represmrtative submitting the report.Include the official signature and the date that the form was prepared, MAIL THE COMPLETED REPORT TO: Chemical Emergency Planning and Response Commission (CEPRC)/ Local Emergency Planning Committee(LEPC) Attn:Section 304 Reports ^- 3650 Schriever Avenue, >p ° -a San Joaquin County Mather CA 95655 a ++ s Environmental Health Department /rI 1868 E.Hazelton Ave..Stockton,CA 95205 MICHAEL J.PARISSI Hazardous Materiats specialist Email:mparissi@sjcehd.com EHD Website:http://www.sjgov.orq/ehd Fax(209) 953-6213 i )468-3433