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S-30-2000 11 :05AM FROM SAN JOAQUIN CO. OES 209 9AA 9015 p. 2 <br /> \ g 2705 BAAIkAYS CALIFORNIA CODE OF REGULA*S RECEPED <br /> JUN 2 7 2001 <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> SANJOAQUIN CUUNIY <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT&PHONE NUMBER OFHCEOFEMERGENCYSERVS <br /> A ELIWO UINE-YAE,% = <br /> 1Z ICY Nos (2�i > 82y - 3y8a <br /> INCIDENT MO DAY YR $?, TIME DES B e"r DATE I ,h NOTIFIED111/1311P (uzr 24 ht tune) �ms CONTROL NO i <br /> b INCIDENT — CITY/COMMUNITY •> COUNTY ZIP <br /> ` "i E} mwN�w a �e�ec�se 11�Iawye ccs 5�, J 95336 <br /> CHEMICAL OP.TRAD NAME(prhtt or typr)n CASNtmber <br /> rT t1 aLrou,s A-mmOnict, 7 610 �{-- y� 7 <br /> FT— <br /> CHECK 1F CHEMICAL IS LISTED IN ,—/ CHECK IF RELEASE REQUIRES NOTIRCATION <br /> 40 CFR}SS.APPENDIX A LTJ I Uri 0ER 42 U.S.C.§960.i(a) - [� <br /> 0 <br /> n PHYSICAL ,�S,TAATE COrN.rT,AI/NED I PHYSICAL STATE RELEAS D QUANTITY RELEASED <br /> . ❑ SOLID L`7 LIQUID L7 CaS ❑ SOLID ❑ LIQUID (GAS <br /> ._. ENVIRONMENTAL CONTAMLNATTON -= TIME OF RELEASE <br /> DURATION OF RELEASE <br /> yR. L✓J AIR ❑ WA7ER❑ GROUND❑ OTHER 4� �D,• �s �. DAYS HOURS MQJUTES <br /> ACTIONS TAKEN <br /> s: <br /> 4- 4tLr n dK, re e,L '- Q <br /> 4ylivt r ease ixa4 rw r,w ,c 44j, 1'r e a.,L. <br /> 2 c�' i Of a �r <br /> 4 fppi, "4�L eL4WegSo r wJL {,(,c CCr� z4jr,Y- ac><ca <br /> el L �o el ofd J-L P <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS( 'Se thT Comments action for additional information) <br /> ACUTE OR IMMEDIATE(explain) w <br /> i <br /> F <br /> El CHRONIC OR DELAYED,(explain) <br /> ' � ❑ NOT KNOWN(explac) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> c e, © k we. rl jL� Ir <br /> COMMENTS INDICATE SECTION(A—G)AND ITEM WITH COMMENTS OR ADDITIONAL INFORMATION)) <br /> a <br /> 2 r¢, o1- C 6S <br /> CERTIFICATION: I hereby certify mtdcr penalty of tow that I have personally cwrnined and I=familiar^•ith the <br /> 'F infamatton submitted and believe the submitted information l:Citi ttvnte.and complete. <br /> 1 REPORTING FACILITY REPRESENTATIVE(print or type) Ens 0. <br /> %a SIGNATURE OF REPORTING FACn=REPRESENTATIVE DATE <br /> Page 120 RcrWa9a.va.la-197-ILLtb <br />