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EMERGENCY RELEASE FOLLOW -UP NOTICE REPORTING FORM <br />RECEIVED <br />OCT 0 8 2015 <br />ENVIRONMENTAL HEALTH <br />PERMITISERVICES <br />a <br />BUSINESS NAME <br />. (Z. Si Ago C.O. - Lwre+eoP <br />FACILITY EMERGENCY CONTACT & PHONE NUMBER <br />6erA..1 CR (2oq) Gti9 - 93q,/ <br />INCIDENT MO DAY YR <br />[DATE p g 2 q r 5 <br />MME <br />OE, <br />(� 3O (use 24 hr time) <br />OES <br />CONTROL NO. t 5 5 2 8 <br />INCIDENTADDRESS LOCATION <br />It.HoLoL Aan RDAD <br />CITY/COMMUNITY <br />L0.rN�P <br />COUNTY ZIP <br />SwJ » 95330 <br />CHEMICAL OR TRADE NAME (print or type) <br />MlH D2oJ oiA G <br />CAS Number <br />{I- 1 <br />CHECK IF CHEMICAL IS LISTED IN <br />40 CFR 355, APPENDIX A © <br />CHECK IF RELEASE REQUIRESNOMFI- <br />❑ <br />CATION UNDER 42 U.S.C. Section 9603 (a) <br />P ITJINE <br />SOLID kSODLQUID <br />P CAL S�S Et GASQN <br />Ip�<to0 <br />ENVIRONMENTAL CONTAMINATION <br />[ZAIR ❑WATER ❑GROUND❑OTHER <br />TIME OF RELEASE <br />1L•,r�} <br />DURATION OF RELEASE <br />—DAYS— HOURaMINUTE <br />IONS TAKEN <br />F L A <br />2. S A <br />`I rE . Iso TAY--rTl <br />[3. <br />M2. fAW41APPA rjAtno r A o." COU.SrY F-#jL).4404L_rA_QtPr /N5PE Z5 <br />P144 'n1ut. IsPCLT of Y3>Yw X50 LTEd. <br />ICIPATED HEALTH EFFECTS (Use the comments section for addition information) <br />R IMMEDIATE (explain) a. Innac.m- mPony - cL_ /(Zsr <br />C OR DELAYED (explain) <br />OWN (explain) <br />LDVICE <br />ING MEDICAL ATTENTION NECESSARY FOREXPOSED INDIVIDUALS <br />I1,V0/ <br />✓ <br />COMMENTS (INDICATE SECTION (A -G)AND ITEM WITH COMMENTS OR ADDITIONAL INFORMATION) <br />sEie ArrAr-+wn C Y <br />o S <br />COfI P201JIflCC� C->rATC <br />CERTIFICATION: I certify under penalty of law that I have personally examined and I am familiar with the information <br />submitted and believe the submitted information is true, aourate, and complete. <br />REPORTING FACILITY REPRESENTATIVE (print ortype) 9,ej a E r -^A <br />SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE: <br />RECEIVED <br />OCT 0 8 2015 <br />ENVIRONMENTAL HEALTH <br />PERMITISERVICES <br />a <br />