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EMERGENCY RELEASE FOLLOW - UP NOTICE REPORTING FORM <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT& PHONE NUMBER <br /> Del-ICAT-t frt+A i IJIN WsA 64,s (2-1 )91.,t -3191 <br /> ] INCIDENT MO DAY YR TIME OES <br /> DATE o O ES use 24 hr time) CONTROL NO. <br /> 7 n 4 t 1 2 5 V I TI s I v I $ <br /> J[I�NC�IDENT ADDRESS LOCATION CITY/COMMUNITY COUNTY ZIP <br /> 001 <br /> 1414,4-W ')M MANT c<,4 SAN Z-442�'N <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number <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 CONTAIN PHYSICAL STAT RELEASED QUANTITY RELEASED <br /> ❑ SOLID ❑LIQUID OGAS ❑SOLID LIQUID ® GAS If.S LBS <br /> ENVIRONMENTAL CONTAMINATION TIME OF RELEASE DURATION OF RELEASE <br /> ®AIR ❑WATER ❑GROUND❑OTHER lrlo Ar+ —DAYS —HOURS 19MINUTE <br /> [ACTIONS TAKEN <br /> T�Id dAw�7�r TANK wAs T o LA'rt 0 4140 A P C Wft' T.va+!• T <br /> SwF-An -eriOL-1 wear ,alta To F,ry TWc L"rw • 74E <br /> rKNOWN OR ANTICIPATED HEALTH EFFECTS (Use the comments section for addition information) <br /> L� ACUTE OR IMMEDIATE (explain) <br /> ❑ CHRONIC OR DELAYED(explain) ___ <br /> ❑ NOTKNOWN (explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> COMMENTS (INDICATE SECTION (A-G)AND ITEM WITH COMMENTS OR ADDITIONAL INFORMATION) <br /> U • �tM17 �- TNllr o� 17 wRS w++i+GO TN q+i +' Jt M" S <br /> S/oY 6•/a(.Da &ugy 1)4qr r,, A M#jvw"Qnj,66eLj Rrzc7, a PrTsaTora W9,4 <br /> WAS ixtD c J cT WAS Fe-vioy" 76S7ep wires /VirRovct' Aho $ +WgWW7 <br /> a*4X opt.u,v[ <br /> CERTIFICATION: I certify under penalty of law that I have personally examined and I am familiar with the information <br /> sub mitted and b elieve the sub mitted information is true, aoauate, and comp I te. <br /> REPORTING FACILITY REPRESENTATIVE (print or type) <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATI TE: G6 lt+! <br />