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r <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT&PHONE NUMBER <br /> J.R.Simplot Company Tim Van Domelen ( 209)858-2511 <br /> g TIME <br /> INCIDENT MO DAY YR SIC EHD Cal-EMA <br /> DATE 911/10 11 NOTIFIED 12:30 9-1-2010(use 24 hr time I CONTROL NO. 10-5247 <br /> INCIDENT ADDRESS LOCATION CITY/COMMUNITY 11COUNTY ZIP <br /> 16777 Howland Road Lathrop I San Joaquin 95330 <br /> CHEMICAL OR TRADE NAME (print or type) I[—CAS Number 1336-21-6 <br /> 27%A uua 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 /> ❑SOLID ®LIQUID ❑GAS ❑SOLID ®LIQUID ❑GAS .tel gallon <br /> ENVIRONMENTAL CONTAMINATION TIME OF RELEASE FDURATION OF RELEASE <br /> ❑AIR ❑WATER®GROUND❑OTHER A roar 12:00 0 DAYS 0 HOURS 30 MINUTES <br /> ACTIONS TAKEN <br /> At approx 12:00 on 9/1/2010 a small drip/leak was discovered on the aqua ammonia beat exchanger unit.The unit was isolated <br /> And drip pans were placed under to catch the dripping liquid.The unit was drained and repaired.A faulty gasket was the cause <br /> of the release.The effected soil was reused in the fertilizer production process. <br /> $ Notification calls were made to County OES,County EHD and Cal-EMA <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS(Use the comments section for additional information) <br /> ® ACUTE OR INTAEDIATE(explain)Inhalation Hazard,Corrosive <br /> F ❑ CHRONIC OR DELAYED(explain) <br /> ❑ NOT KNOWN(explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> Move victim to fresh air and contact 911 <br /> COMMENTS (INDICATE SECTION(A-G)AND ITEM WITH COMMENTS OR ADDITIONAL INFORMATION) <br /> d1___ - .1 <br /> 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 REPRESENTATIW (/::;,> `— DATE: 9.5-2010 <br />