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0 0 <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> BUSINESS_NAMEEACIUTY EMERGENCY CONTACT&PHONE NUMBER <br /> Q '<<. '• 1{; t:ti [ht �>E 37C <br /> INCIDENT 110 DAY YR TIME OES <br /> DATE / OES � � (use 24 Ir lime) CONTROLNO. <br /> INGDENT ADDRESS LOCATION CITY/CO4MMUNITYCOUN� ZIP <br /> CHEMICAL OR TRADE NAME (print or type) CAS Ntmber /3 <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFI- <br /> 40 CFR 355, APPENDIX A 1K CATION UNDER 42 U.S.C. Sec5on9603(a) <br /> PISOLIDTA�DUID CONTAINEDGAS POSO DST[ZLIO DATE S❑ GAS ED QUANTITY RELEASED <br /> Ciif r5 <br /> EWIRONNIENTAL CONTAMINATION y`,+C�';rL. TIMEOFRELEASE DURATION,I``O�FRELEASE <br /> AIR WATER QGROUND�OIHQ2 ',�j _DAYS LIHOURS�5NIINU <br /> FACITION�,STARNI ")!_� 9'r .7.pC f '.L.l <br /> KNOM OR ANTICIPATED HEALTH EFFECTS (Use the mmmenb ectim for addition infannetion) <br /> ® ACUTE OR IMMEDIATE(m+plain) .>✓� �.+ ',2_ T - .5 ..'h,n <br /> CHRONIC OR DELAYED(explain) <br /> NOTKNOM(explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> i l <br /> COMMENTS (INDICATE SECTION tA-G)ANDITEMWTHCOMMENTSORADDMONALINFORMAT10N) <br /> CERTIFICATION: I certify under penalty of law that I have personalty examined and I am farriliar with the irfoimatim <br /> submitted and believe the sub ndtted information is true,aovrgSe and complete <br /> REPORTING FACILITY REPRESENTATIVE (Print or type) _i J_ A' 5 <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE L,.k v..�r,S,c DATE'. "f7 "(_' ( j <br />