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EMRGENCY RELEASE FOLLOW-UP NOTICE <br /> San Joaquin County Environmental Health <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT&PHONE NUMBER <br /> J.R. Simplot Company Tim Van Domelen ( 209)858-2511 <br /> $ TIME <br /> INCIDENT MO DAY YR OES OES <br /> DATE " 8127109 11 NOTIFIED 1035 (use 24 hr time) CONTROL NO.09-5949 <br /> INCIDENT ADDRESS LOCATION CITY/COMMUNITY COUNTY ZIP <br /> 16777 Howland Road Lathrop San Joaquin 95330 <br /> CHEMICAL OR TRADE NAME (print or type) CAS Number 7664-93-9 <br /> Sulfuric Acid 98% <br /> CHECK IF CHEMICAL IS LISTED IN fCHECK IF RELEASE REQUIRES NOTIFICATION <br /> 40 CFR 355,APPENDIX A I UNDER 42 U.S.C. SECTION 9603(a ❑ <br /> PHYSICAL STATE CONTAINED PHYSICAL STATE RELEASED QUANTITY RELEASED <br /> ❑SOLID ®LIQUID ❑GAS ❑ SOLID ®LIQUID ❑ GA 120 to 25 Gallons <br /> ENVIRONMENTAL CONTAMINATION TIME OF RELEASE DURATION OF RELEASE <br /> ❑AIR ❑WATER®GROUND❑OTHER 11 0200 0 DAYS 0 HOURS 5 MINUTES <br /> ACTIONS TAKEN <br /> During the process of changing a faulty valve,20 to 25 gallons of sulfuric acid was released,an unknown amount of that quantity <br /> reached an adjacent soil area. <br /> E <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS(Use the comments section for additional information) <br /> ® ACUTE OR IMMEDIATE(explain)Skirl 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 (INDICATE SECTION(A-G)AND ITEM WITH COMMENTS OR ADDITIONAL 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 /> r <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE: �i <br />