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EMERGENCY RELEASE FOLLOW- UP NOTICE REPORTING FORM <br />CHEMICALTRADE NAME (prinSS or type) CAS Number <br />502..'&A' '7 `134 <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) <br />PHYSICAL STATE CONTAINED PHYSICAL STATE RELEASED QUANTITY RELEASED <br />[:]SOLID ®LIQUID [:]GAS ❑SOLID ®LIQUID [:]GAS G Gall <br />ENVIRONMENTAL CONTAMINATION IVO -Ne TIME OF RELEASE I DURATION OF RELEASEE <br />❑AIR [:]WATER ❑GROUND❑OTHER 1120 —DAYS—HOURS=MINUTE <br />ACTIONS TAKEN <br />4 r Q <br />` o �► r <br />a 6 N«» <br />heti a/'2;C -4, <br />L_J <br />b41 d"At;Mi 2 <br />KNOWN OR ANTICIPATED HEALTH EFFECTS <br />® ACUTE OR IMMEDIATE (explain) // <br />F—]CHRONICOR DELAYED (explain) <br />❑ NOTKNOWN (explain) <br />I A <br />I DVICE REGARDING MEDICAL ATTE1VTION NE <br />Gin 1, ve/i CON�Ni h CJ <br />C, P"Fyf fre Ps e <br />.h u Ig ye4 <br />eel w Pr Y h <br />h v w�M <br />S 4 IAC. . <br />(Use the comments section for addition information) <br />COnfoft Wf,A sh,*4 0 eyes <br />ED INDIVI <br />C0yf'bC1'-r Or eye4. <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, accurate, and wm lete/'� <br />REPORTING FACILITY REPRESENTATIVE (print or type) QG . ' ID <br />SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE: <br />