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Summary of Laws and Regulations for 1°Iy//,Ery//Si� <br /> *CA O"ES <br /> CaJOES Hazardous Material Spill / Release Reporting <br /> BCYERROR'S OFFICE <br /> OF EMEROENuv SERVICES <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> ❑ BUSINESS NAME FACILITY EMERGENCY CO NTA CF PHONE NUMBER <br /> A <br /> INCIDENT MO DAY YR TIME Cal EMA <br /> B Cal EMR [Use 24hr Tl me] <br /> DATE NOTIFIED CONTROL NO <br /> I NO D ENT AD DRESS LOCATIO N CFFY/COM MUNFFY COUNTY ZIP <br /> CH E M ICA L OR TRA DE NA ME(pr int or type) CAS Nu m he r <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFICATION <br /> 40 CF 8355,APPS NOW A ❑ UNDER42 U.S.0§9603(a) ❑ <br /> D <br /> PHYS ICA L STATE CONTAINED PHYSICAL STATE RELEA5ED QUANTITY RELEASED <br /> ❑SOLID F-ILIQUID []GAS SOLID ❑LIQUID GAS <br /> ENVIRO NMENTA LCONTAMINATION TIME or RELEASE DU RATIO NOFRELEAS E <br /> ❑AIR [71 WATER ❑GROUND MOTHER DAYS HOURS MIN <br /> ACTIO NS TA KE N <br /> E <br /> I <br /> NOWN OR A NT ICI PATED HEALTH EFFECTS(Use comme Fits section for additional information) <br /> ACUTE OR IMMEDIATE(Explain) <br /> ❑ CHRONIC OR DELAYED(Explain) <br /> ❑ NOT KNOWN(Explain) <br /> ADVICE REGARDING M EDICA I.ATTE NT ION NECESSARY FOR EXPOSED INDIVIDUALS <br /> G <br /> COMMENTS:INDICATE SECTION(A-G)AND ITEM WITH CO M ME NTS 0 R A DDITIO NA I.INFORMATION <br /> H <br /> CERTIFICATION, I hereby certkfy under penalty of law that I have personally ex amin ed and I am fam Iliar with The In for matlan submitted and believe the <br /> subm Itted information is true,amu rate,and complete. <br /> REPORTING FACILITY REPRESENTATIVE(printar type) <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE <br /> Form 301 D71t011 <br /> Page 12 California Governor's Office of Emergency Services 3650 Schriever Ave Mather, CA95655 Fe <br /> 2014 <br />