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SPILL OR RELEASE NOTIFICATION <br /> In the event of a spill, have the following information available <br /> State and Local Notification: <br /> HEG"'ANED <br /> FEB 0 6 2017 <br /> 1. Name of business: <br /> HEALTH <br /> 2. Identity of caller: DEPARTMENT <br /> 3. Chemical name and quantity released (if known): <br /> 4. Description of what happened: <br /> Was the re easl acontained?- --Yes No— <br /> Please describe if release entered any waterway or storm drains: <br /> 6. Information about the spill, release or threatened release: <br /> a. <br /> Location: <br /> b. Date: <br /> --C-.�: Ti e•d. Injuries or Fatalities? <br /> e. Evacuation conducted? <br /> e Clean-up by: <br /> Federal Notification: <br /> Federal Notification required additional information for spills (CERCLA <br /> chemicals) that exceed federal reporting requirements, which includes: <br /> a. Medium or media impacted by the release <br /> n. Time and duration of the release <br /> c. Proper precautions to take <br /> d. Known or anticipated health risks <br /> e. Name and phone number for more information <br />