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� a <br /> .c <br /> f � <br /> RECEIVED <br /> I <br /> SEP 0 9 2011 <br /> EMERGENCY RELEASE FOLLOW-UR NOTICE REPORTING FORM <br /> U>BUESS NAME FACILITY EMERGENCYCONTACTI&PHONE NUMBER tt, NMEN-ALHEALTH <br /> t><tC_ C-rw rat-S`�tyclrr Ki ctrl, wN a ( ) d 5 4MfT/SER'I/IC�3 <br /> INCIDENT MO DAY YR TIME OE5 <br /> DATE2 5 1 111.01 OES I 3 (use 24 hr time) CONTR.PLNO. t S I 4 <br /> INCIDENT ADDRESS LOCATION Eul1 CITYICOMMUNITY I COUHTY ZIP <br /> R14V1t_ETi4 rr.► L 302 vY Op. STUJCrbtA SAdaBjQir4 9�ZO�a <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number <br /> CHECK IF CHEMICAL 1S LISTED IN CHECK IF RELEASE REQUIRES NOTIF1- <br /> 40 CFR 355, APPENDIX A CATION UNDER 42 U.S,.C. Section 9603(a) <br /> PJ SO IDHUICAL TAZLLIQUIDINTIGAS PSO DLIDCAL ST LIQUEIDS GAS I QUANTITY RELEASED <br /> 3S L. <br /> . - - <br /> ENVIRONMENTAL CONT!_1MEIN TION NTME OF RELEASE IDURf TION OF RELEASE ` <br /> 2JAIR E]WATER GROUNDQOTHER ti`s;On ®p Yg:�!__H0URS&INUTE <br /> ACTIONS TAKEN f <br /> A5 PAMT o N'Cn Pr-! S 6 A fsS o� <br /> M. T WA-re- RvLo m <br /> u � T tw Cf3u t- B <br /> it <br /> KNOWN ANTICIPATED HEALTH EFFECTS (Use the comments section far additian Information) <br /> ACUTE OR IMMEDIATE(explain) (m RALAm o tJ i <br /> 2rCHRONIC OR DELAYED(explaln) LbtAt, Tt& & WmAce <br /> NOTKNOWN (explaln) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPO ED INDIVIDUA',LS <br /> Stat g 'Y(-_ t SC ue <br /> L�MCAL, CAR-e- Czt, <br /> COMMENTS (INDICATE SECTION (A-G)AND ITEM WTH COMMENTS OR ADDITIONAL INFORMATION) <br /> E 'z- A fir, ' <br /> f t <br /> CERTIFICATION: I certify under penalty of law that i have personally examined and I am familiar with the information <br /> •submitted and believe the submitted information is true;aowrat nd-oamplete. ) <br /> REPORTING FACILITY REPRESENTATIVE (print or type) RL C <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE -tDATE: <br /> t I <br /> i <br /> 3 r( I <br /> . M <br />