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EMERGENCY RELEASE FOLLOW-UP NOTICE p�I <br /> SAN 30AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> A� BUSINESS NAME II FACILITY EMERGENCY CONTACT&PHONE NUMBER <br /> tI d.R Simplot Company Tim Van Domelen ( 209)858-2511 <br /> YR TIME <br /> IME <br /> Cal-EMA <br /> INCIDENT MO DAY <br /> DATE 12/2!09 NOTIFIED 0730 1213/09(usc 24 hr time) CONTROL NO.09-8065 <br /> INCIDENT ADDRESS LOCATION CITY/COMMUNITYCOUNTY ZIP <br /> 16777 Howland Road Lathrop San Joaquin 95330 <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number 1336-21-6 <br /> Ammonium Hydroxide(Aqua Ammonia <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFICATION <br /> 40 CFR 355,APPENDIX A ❑ UNDER 42 U.S.C.SECTION 9603 a ❑ <br /> PHYSICAL STATE CONTAINED PHYSICAL STATE RELEASED QUANTITY RELEASED <br /> 0 SOLID ®LI UID ❑GAS ❑ SOLID ®LIQUID 0 GAS <50 Gallons <br /> ENVIRONMENTAL CONTAMINATION TIME OF RELEASE 11 DURATION OF RELEASE <br /> ❑AIR D WATER®GROUND❑OTHER j 1 2030 0 DAYS 0 HOURS 5 MINUTES <br /> ACTIONS TAKEN <br /> On 12/2/09 Q approx.2030 a gasket on a pipe leading to and from Aqua Ammonia process unit A14-2 failed at a blind flange. <br /> Gaskets in area have been inspected and replaced. <br /> Notification calls were made to County OES,County EHD and Cal-EMA.#09-8065. <br /> E <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS(Use the comments section for additional information) <br /> ® ACUTE OR IMMEDIATE(explain)Skin and eye contact-corrosivity <br /> F ❑ CHRONIC OR DELAYED(explain) <br /> ❑ NOT KNOWN(explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> Flush any contacted areas of the body with large amounts of water. <br /> COMMENTS -(INDICAI'E.SECTION-(A-G)AND ITEM WITH COMMENTS ORADDITIONAL INFORMATION). <br /> j CERTIFICATION:I certify under penalty of law that I have personally examined and am familiar with the information submitted and <br /> Believe the submitted information is true,accurate,and complete. <br /> REPORTING FACILITY REPRESENTATIVE(print or type)Ryan Mock,Environmental Specialist <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIV<�� DATE: h 0 <br />