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RECEIVED, <br /> EMERGENCY RELEASE.FOLLOW-UP NOTICE REPORTING FORM MAY 05 2011 <br /> BUSINESS NAMEFgCIUNEMERGENCY CONTACT&PHONE NUMBER7 <br /> 1 G"[Nr•Vn+v ST -c K RONMckrra HEALTHI <br /> DES ERMIT/SERVICES <br /> INCIDENT MO DAY YR 71ME <br /> DATE pq. 2 ( I Oa ' -� ' 7 (use 24 hr time) CONtROLNO. i 2 <br /> INCIDENT ADDRESS LOCATIONCIN/COMMUNITY COUNTY ZIP 952oco <br /> 3028 11rtv a E roc.k-ro M SNS Jo R <br /> CHEMICALORTRAKENACIME (print orlype) <br /> cJULFJ21 tR <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFI- ❑ <br /> 40 CFR 355, APPENDIX A CATION UNDER 42 U.S.C. Section 9603(a) i <br /> an F HICPL SOLID 1 LIQU D C N IN GAS P SO SCAL OLID QUIDS GAS 1 e.5 16S R l2 GRELD. <br /> NI ENVIRONMENTAL CONTAMINATION TIMEOFRELEASE DURATION OF RELEASE <br /> AIR [:]WATERQGROUNDOTH ER 15oC4 - 'DAYS 4HOURS�MINUTE ' <br /> I <br /> ACTIONS TAKENtN <br /> M _ A - - E <br /> c �v <br /> _ I <br /> _ _ _r-A __Erm� NQXI S - 10 NNAPCLD <br /> P C �n <br /> �roCO\1E 2 j <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS (Use Vie comments section for addition Information) <br /> ¢ <br /> ACUTE OR IMMEDIATE(explain) IULFo rel C_^AC-l0 1 <br /> CHRONIC OR DELAYED(explain) <br /> _ NOTKNOWN(explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS LemT <br /> Mr R _ fvxlry Toa <br /> • SOS <br /> COMMENTS (INDICATE SECTION (A-.G)AND ITEM WTH COMMENTS ORADDITIONAL INFORMATION) <br /> L L-e "' l 6 Ov t ! <br /> W T <br /> M <br /> t ILFc� I <br /> - I <br /> i <br /> CERTIFICATION: I certify under penally of law that I have personally examined and I am familiar with the information <br /> submitted and belleve the submitted information is true,qw, te,and complete. - <br /> REPORTING FACWTYREPRESENTATIVE (print or type) f-sD <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE: - "I <br /> i <br /> j <br /> t <br /> • I <br /> • 1 <br />