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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 :1 Person Spoken to: <br /> DATE 8-7-08 NOTIFIED 1445 (use 24 hr time) She l/Michelle Henry <br /> FINCIDENT 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 C14EMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFICATION <br /> 40 CFR 355,APPENDIX A R UNDER 42 U.S.C.SECTION 9603(a) ❑ <br /> PHYSICAL STATE CONTAINED P14YSICAL STATE RELEASED QUANTITY RELEASED <br /> ❑ SOLID ❑LIQUID ❑GAS ❑ SOLID ® LIQUID ❑GAS I Approx. 100 Gallons <br /> ENVIRONMENTAL CONTAMINATION TIME OF RELEASE DURATION OF RELEASE <br /> ❑AIR ❑WATER® GROUND❑ OTHER 1415 DAYS HOURS 45 MINUTES <br /> ACTIONS TAKEN <br /> A pipe failure occurred at tank 8 pump area resulting in a release to the surrounding soil inside the"ring wall"area.A temporary <br /> clamp was installed to stop the leak while the tank was pumped out so permanent repairs could be made.The leaked acid was <br /> neutralized during response activities and affected soil will be removed and properly disposed. While the tank is empty a <br /> complete internal inspection will be conducted. <br /> E AMOUNT OF HAZARDOUS WASTE CREATED Approx 15 yds <br /> DISPOSITION OF HAZARDOUS WASTE: Rocky soil will be classified and properly disposed of at a suitable landfill. <br /> dF KNOWN 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 /> 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. 08-5732 <br /> NRC Called?Yes Report No.879941 <br /> 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 Dome en, S ks Ma er <br /> DATE: �� <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE <br /> I <br />