Laserfiche WebLink
06 08 11 <br /> JUNZs <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> BUSINESS NAME FACILITY EMERGENCY CONTACT&PHONE NUMBE RMI S�TgI y�rq <br /> Pacific Ethanol Inc. Kirk Lund (209 )542 -0557 RV/Cta <br /> TIME DES <br /> INCIDENT MO DAY YR 113 4 7 0 <br /> DATE MO 19) I OES I � 30 (use 24 hr time) CONIROLNO <br /> INCIDENT ADDRESS LOCATION CIN/COMMUNITY COUNTY ZIP <br /> 3028 Navy Drive Stockton San Joaquin 95206 <br /> CHEMICAL OR TRADE NAME (pont a type) CAS Number <br /> E-z•,�,y,o� Ca4-1�-5 <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES N011FI- E]40 CFR 355, APPENDIX A CATION UNDER 42 U.S.C. Section 9503(a) <br /> PHYSICAL STA CONTAIN D PH SICAL STATE RELEASE QUANTITY REL SED <br /> ❑SOLID LIQUID E❑GAS SOLID ❑LIQUID GAS 26AU_0 12 <br /> ENVIRONMENTAL CONTAMINATION TIMEOF RELEASE I DURATION <br /> II��OF RELEASE <br /> SrAIR ❑WATER ❑GROUND❑OTHER QA Q-DAYS31-HOURIMMINUlE <br /> LIONS TAKEN huatmik OF A L P J L_ IIJ L E <br /> R Covet wns IN 1 E Wme%;t Co A FN 2 D v <br /> r,4t'l P ClL n1 Lj OCFSS <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS (Use the comments section for addition information) <br /> ACUTE OR IMMEDIATE(explain) sy a \T \sK of �H't,DAMA <br /> CHRONIC OR DELAYED(explain) Ar.+D IN'1hxtCA-C101A LUNFrS I t <br /> ❑ NOTKNOWN (explain) fCrSj0Lg. \15 VC \TI C+i NGr1VG7 SYS'cFia. PCPRESSi <br /> DVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> T LY EYES OCL '-[ FO2 T <br /> L.E %T tS Mlu0Gjq- WRP,A I nl cMAA L)tk1i 'i <br /> Tp N 2 Iq R2 O � D C4'` CReE, <br /> COyM�M.�ENTS (INDICATE SECTION (A-G)AND ITEM WITH COMMENTS OR ADDITIONAL INFORMATION) <br /> E LJ=r1tL OCW R(tE \ ItA MP-FGt2A L <br /> REcove2g-0. Ate- tkkAii IEIAS CIE- Cwt <br /> 1 F1 R <br /> E r R a U , A6%R,5AI47 <br /> Ads USCG 1D\yk\n16 C-eW UP EAE \E W IC [SS R tSPSAL <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,accurate,and complete. <br /> REPORTING FACILITY REPRESENTATIVE (print or type) K rk Lun <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE: <br />