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EMERGENCY RELEASE FOLLOW -UP NOTICE REPORTING FORM <br />BUST E NAME <br />0 i ori 'a <br />INCIDENT MO DAY YR <br />DATE IDI6I-LIcIco1 <br />FACILITY EMERGENCY CONTACT & PHONE NUMBER <br />cTa c /f &J"5404 109466- 6 31`t - <br />TIME OES <br />OES(use 24 hr time) OL NO <br />CONTROL Iolil IgiSlo <br />m_ � VC]71FIF <br />INCIDENT ADDRESS LOCATION <br />CITY/ COMMUNITY <br />COUNTY ZIP <br />�o S. Cc j96&.40-0ST . <br />STo�'� <br />z <br />FEMICAL 0 TRADE NAME (prin or type) CAS Number <br />a 2;G► K. /m/ crvxi'J� `l7 32 <br />HECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOT1F1 ❑ <br />F <br />0 CFR 355, APPENDIX A CATION UNDER 42 U.S.C. Section 9603 (a) <br />PHYSICAL STATE CONTAINED <br />❑ SOLID X LIQUID [:]GAS❑ <br />PHYSICAL STATE RELEASED QUANTITY RELEASED <br />SOLID ® LIQUID ❑ GAS <br />ENVIRONMENTAL CONTAMINATION Oqe TIMEOF RELEAJ—DAYS—HOURA <br />DURATION OF RELEASE <br />[:]AIR E] WATER ❑GROUND❑OTHER /J2pMINUTE <br />ACTIONS TAKEN <br />4 e a en fj ee% Ohfw 'h <br />coh ✓ a ".enf I, P4 e <br />a @ u.« E ih u CDH 4 ' e✓ e4 <br />,h e &f u l, Ze C � h e� w Ps' r <br />611212 se Ki a 0t. h ww l <br />o h 'M; 2 e4tp✓� <br />KNOWN OR ANTICIPATED HEALTH EFFECTS (Use the comments sections for addition information) <br />Cogf�C%� W;/`� S�7 �! O� <br />® ACUTE OR IMMEDIATE (explain) /� <br />❑ CHRONIC OR DELAYED (explain) <br />❑ NOTKNOWN (explain) <br />ADVICE REGARDING MEDICAL ATTE TION NECESSARY JOR EXPOSEID INDIVIDUAkS <br />OM apt H Or <br />tea; � ,N sys <br />COMMENTS (INDICATE SECTION G)AND ITEM WITH COMMENTS ORADDITIONAL INFOf2MATION) <br />t -a <br />.t f f ✓lit % CON G h !'o( l' o e y vi Yoh w. e y <br />*&I Q M4 '&r- Ar! ex O e �%r OS4I� <br />j?efgAj&-.ravel cle*t!U ^- ale f !✓ ' o <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 com fete. <br />REPORTING FACILITY REPRESENTATIVE (print or type) <br />DATE: ' <br />SIGNATURE OF REPORTING FACILITY REPRESENTATIVE <br />