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0 i <br /> 06 08 11 <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> BUSINESS NAME FACIUTY EMERGENCY CONTACT&PHONE NUMBER <br /> Pacific Ethanol Inc. Kirk Lund (209 )542 -0557 <br /> INCIDENT MO DAY YR <br /> 1OES <br /> DATE � �p IIDII SII OES II 14Jojsl(use 24 hr time) CO N TRO L N O. 11IIIJITI 1I <br /> INCIDENT ADDRESS LOCATION T CITYI CO MM U N ITY COUNTY ZIP <br /> 3028 Navy Drive Stockton San Joaquin 95206 <br /> CHEMICAL OR TRADE NAME (print a type) CA Number <br /> c-atR"4b%-. 1j! <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFI- ❑ <br /> 40 CFR 355 APPENDIX A CATION UNDER 42 U.S.C. Section9003(a) <br /> PHYSICAL STAT CONTAINED PHYSICAL STA E RELEASED QUANTITY RELEASED <br /> ❑SOLID ,LIQUID ❑GAS ❑SOLID LIQUID ❑ GAS 15G lW1jS <br /> ENVIRONMENTAL CONTAMINATION TIME OF RELEASE DURATION OF RELEASE <br /> [:]AIR ❑WATER ❑GROUND®OTHER Iq � ! <br /> ' DAYS QH O U RS3-OMINUTr. <br /> L--JlACTIONS TAKEN <br /> WaR Da\ucf- ovE2\o O- l-IIS TrZUG< <br /> 0RM F l u - IS 114LAonS WEMI INA <br /> c N A0. e C KER - T e <br /> WAS RObileezr> s N 02 UA1l-- <br /> CASOYIM6C1cE T L TO ?,E g E I wr <br /> rNRCIPATED HEALTH EFFECTS (Use the comments section for addition information) <br /> R IMMEDIATE(explain) E`(ESKW \T _ (�OR DELAYED(explain)1NNAL N W TI m QnsI VWN (explain)NG MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> K \ L6A <br /> TC �� \ H t-A.TI IMMEOIgTEI'l M®SSE � FAESN A <br /> UR AND o cN AS Kr..DCD ' IJW SEciA MWi(AC aE <br /> VCOMMENTS (INDICATE SECTION (A-G)AND ITEM WTH COMMENTS OR ADDITIONAL INFORMATION) <br /> HK \ LRUtl- La E <br /> SECpKflAIRY COt4TRlMYIeMT� �O.r] LAP_(y2�0 <br /> --F A tt pI6AI SE DA -( <br /> CWTAit4PAZNIT W E2E I-c E2Efl So TLMA-E 14 Sk W AS <br /> - <br /> E�A - C <br /> CERTIFICATION: I certify under penalty of law that I have personally examined and 1 am familiar with the information <br /> submitted and believe the submitted information Is true,aoarrate,and complete. <br /> REPORTING FACILITY REPRESENTATIVE (print or type) Kirk Lund <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE DATE: <br />