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i 0 <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> San Joaquin County Environmental Health <br /> For spills to the environment or employee injuries from chemicals <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT&PHONE NUMBER <br /> J.R. Simplot Company Tim Van Domelen ( 209)858-2511 <br /> TIME <br /> INCIDENT MO DAY YR SJ EH [Muniappa <br /> erson Spoken to: <br /> DATE 8-13-0$ NOTIFIED 0800 8-14-08 (use 24 hr time) Naidu <br /> INCIDENT ADDRESS LOCATION CITY/COMMUNITY COUNTY ZIP <br /> 16777 Howland Rd Lathrop San Joaquin 95330 <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number 7664-93-9 <br /> Sulfuric Acid <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFICATION <br /> 40 CFR 355,APPENDIX A ® UNDER 42 U.S.C. SECTION 9603 a ❑ <br /> PHYSICAL STATE CONTAINED PHYSICAL STATE RELEASED QUANTITY RELEASED <br /> ❑ SOLID E LIQUID ❑GAS ❑ SOLID ® LIQUID ❑GAS I I Approx. 5 Gallons <br /> ENVIRONMENTAL CONTAMINATION I TIME OF RELEASE DURATION OF RELEASE <br /> ❑AIR ❑WATER® GROUND❑OTHER 110015 DAYS HOURS 10 MINUTES <br /> ACTIONS TAKEN <br /> During hourly screenings operator noticed a leak in one of the elevated sulfuric acid lines leading to the pellet plant.Pumps were <br /> isolated and leaked acid was neutralized.Repairs were made and neutralized acid was washed to the internal sump system for <br /> reuse in process.No injuries or evacuations. <br /> E <br /> AMOUNT OF HAZARDOUS WASTE CREATED:None <br /> DISPOSITION OF HAZARDOUS WASTE:Acid was neutralized and washed into the sump system for reuse in the process <br /> IFKNOWN OR ANTICIPATED HEALTH EFFECTS(Use the comments section for additional information) <br /> ® ACUTE OR IMMEDIATE(explain)Skin or eye contact-corrosive <br /> ❑ 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?Yes Control No.08-5767 <br /> NRC Called?No Report No. <br /> 1 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 Dqmelen,FHS S Manager <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE IT DATE: <br />