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EMERGENCY t<ELEASE FOLLOW- UP NOTICE REF-uRTING FORM <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT& PHONE NUMBER <br /> CORN PRODUCTS K Rocrer Hoffdahl ) <br /> INCIDENT MO DAY YR TIME 0ES <br /> DATE 0 2 3 1 2 0' 15 2 0 (use 24tvtime) CONTROLNO. 2 12 14 12131 <br /> INCIDENT ADDRESS LOCATION CITY/COMMUNITYCOUNTY f <br /> 1021 Industrial Drive Stockton San J a <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number MAY AI 2012 <br /> Hydrated Lime Slurry 1305-62-0 <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUI ALyHEA.L <br /> 40 CFR 355, APPENDIX A 1:1CATION UNDER 42 U.S.C. Section Y^"" <br /> PHYSICAL EASED <br /> SOLIDT QU DINEtGAS P SO DCALST�LIQUIDRELEASTI GAS QU750 galANTITY l ons <br /> _jjENUVuIRONMENTALCONTAMINATION TIMEOF RELEASE DURATION OF RELEASE <br /> ❑AIR [::]WATER ❑GROUND❑OTHER 21400 &DkYYS2--HOURSOJMINUTE <br /> ACTIONS TAKEN <br /> Upon discovery, manual valve closed to stop water flow to the <br /> storage tank. Tank level instrumentation failed causing the dilut ' on <br /> valve to open and overfill the tank. The majoritv of the materia <br /> spilled into the tank secondary containment, ar)iproximately 250 qaLs <br /> spilled onton i ille material washed to <br /> a holding tank and used in the w H ad ' ust system by desi n, <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS (Use the comments section for addition information) <br /> ® ACUTE OR IMMEDIATE (explain) <br /> ❑ CHRONIC OR DELAYED(explain) <br /> ❑ NOTKNOWN (explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> No exiposure occurred, <br /> COMMENTS (INDICATE SECTION (A-G)AND ITEM WITH COMMENTS OR ADDITIONAL INFORMATION) <br /> Non-emerc[ency notification made to the City of Stockton Fire Dept <br /> MUD and the SJC Environmental Health (CUPA) . State warning center <br /> contact Chuck report # EMA 12-2423. On-site inspection by the <br /> Fire Dept, Engine #3 C t Salvestrin & County EHS, R Von Flue. <br /> CERTIFICATION I certify under penalty of law that I have personalty examined and I am familiar with the information <br /> submitted and believe the submitted information is true, aowrate, and complete. <br /> REPORTING FACILITY REPRESENTATIVE (printortype) rhrig T7.impnapfis . Operations Mar <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE: <br /> jtL- <br /> COPY <br />