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EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> SEP 1 5 2008 <br /> San Joaquin County Environmental Health ENVIFtONiViibJ i HEALTH <br /> For spills to the environment or employee injuries from chemicals PEMI T,SERVIGES <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT&PHONE NUMBER <br /> J.R. Simplot Company Tim Van Domelen ( 209)858-2511 <br /> B TIME <br /> INCIDENT MO DAY YR SJ EH Person Spoken to: <br /> DATE 9-8-08 1 NOTIFIED 850 (use 24 hr time) Sheryl/Ra Von Flue <br /> INCIDENT ADDRESS LOCATION CITY/COMMUNITY COUNTY ZIP <br /> 16777 Howland Rd Lathrop an Joaquin 95330 <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number 7664-38-2 <br /> Phosphoric Acid 11 1 <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFICATION <br /> 40 CFR 355,APPENDIX A Z UNDER 42 U.S.C. SECTION 9603 a ❑ <br /> PHYSICAL STATE CONTAINEDPHYSICAL STATE RELEASED QUANTITY RELEASED <br /> E] SOLID Z LIQUID E]GAS A[] SOLID ® LIQUID [:] GAS Less than 5 gallon <br /> ENVIRONMENTAL CONTAMINATION TIMEOF RELEASEURATION OF RELEASE <br /> ❑AIR E] WATER Z GROUND F] D <br /> OTI4ER 810 DAYS HOURS 2 MINUTES <br /> ACTIONS TAKEN <br /> Leak was noticed coming from an elevated transfer pipe leading to the phos acid storage tank. Pumps were shut down and clamp <br /> was installed to temporarily stop the leak until permanent repairs could be made.Acid was neutralized and effected soil was <br /> removed and will be reused in the plant.Pipe is scheduled to be replaced. <br /> E AMOUNT OF HAZARDOUS WASTE CREATED 1/2cubic yard <br /> DISPOSITION OF HAZARDOUS WASTE Not hazardous waste,product reused in plant <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS(Use the comments section for additional information) <br /> ACUTE OR IMMEDIATE(explain)Skin or eye contact-corrosive <br /> F ❑ CHRONIC OR DELAYED(explain) <br /> ❑ NOT KNOWN(explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> C Flush any contacted areas of the body with large amounts of clear water. <br /> COMMENTS (INDICATE SECTION(A-G)AND ITEM WITH COMMENTS OR ADDITIONAL INFORMATION) <br /> B. State OES Called?No Control No. <br /> H 1 NRC Called?No Report No. <br /> I CERTIFICATION:I certify under penalty of law that I have personally examined and am familiar with the information submitted and believe <br /> the submitted information is true,accurate,and complete. <br /> REPORTING FACILITY REPRESENTATIVE(print or type)Tim Van D melen E Manage <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE [)A H <br /> C <br />