Laserfiche WebLink
of <br /> Road Dist . � HAZARDOUS MATERIALUL 2 0 1987 Case w <br /> Fire Dist. of'. NOTIFICATION FORM Class <br /> ENVIROMENTAL HEALTH Level <br /> -:Y-- <br /> PERMIT/SERVICES <br /> A. Date: ` _ -• 1 Present Time: x l�-,� fi Incident Time: fes ' .} <br /> B. Reported by: _ �F ;-{ ��_s -- Home Telephone; <br /> C. Home Address: <br /> Street name & Number City Zip <br /> D. Calling From: � r Cyr-,Q- / ryr1I' Telephone: <br /> ' Address City <br /> E. Type of Incident: [ j Explosion [>4 Spill [ ] Leak [ ] Crash [ ] Fire <br /> [ ] Irritant [ j Abandon/dumped [ j Other: <br /> F, What Happened: A[ r 3,- S=i,P Lf 14:y ' <br /> G. Number of Injuries: ,r1 By Material: C( Type: <br /> T- / <br /> EXACT LOCATION Address: 1�-1_ f :�.�u 41Jwo 1,,f+t <br /> �/f <br /> H. Name of Business: �!.z) CC<.�,,t4j. ',�.x;, ;I lfJ/�/!J ��4� YJ�yut <br /> I . Type of Structure: �1 ��� lit/, rklC -t , <br /> J. VEHICLE(s) ; I .D.#: Lic.#: State: <br /> T K. Environment Affected: [ j Soil : [.ti] Road: _ <br /> [ ] Water: [ ] Air: <br /> L. Population: [ ] None Urban [ ] Rural [ ] Business [ j Industrial <br /> M. Weather: Wind mph From ° Temp____2 Humidity � Other <br /> N. Evacuation/Shelter Action: /f.&,N P When: <br /> IDENTIFICATION OF MATERIAL <br /> 0. Substance Form: [ ] Solid [ j Powder Gas [ j Liquid [ j Granule <br /> P. Type of Container: Condition: <br /> Q. Quantity of Material: _ - c)41 <br /> R. Trade Name: rte^, sol iArA� Chemical Name: <br /> S. UN & EPA Number: Q Hazard Class: Rt,tA,�-, L 1 C.L,-31, <br /> I� <br /> T. Placard Description: Placard No. : <br /> U. Manufacturer's Name: ` Cn Telephone: ( - ) - <br /> V. Shipper's Name: Telephone: ( <br /> W. Carrier's Name: Telephone: ( <br /> X. Consignee Name: Tel ,hone: <br />