Laserfiche WebLink
• • RECEIVED <br /> MAY 10 2012` <br /> EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM ENVIRONMENTAL <br /> HEALTFI <br /> FER B SINESS NAME FACILITY EMERGENCY CONTACT&PHONE NUMBER IT/SERVICES <br /> cl 4 EZ OL �Wri� (209: _0370 <br /> INCIDENT MO DAY YR TIME DES /• <br /> DATE V q. Z -7 ( OES ( a (use 24 hr tare) CONTROL NO. ( 2 2 3 <br /> i <br /> INCIDENT ADDRESS LOCATION CITY/COMMUNITY ' COUNTY ZIP I. <br /> �0 N Y �21U' STOU<TotJ A't 3QPCLQw �S20Co pp <br /> CHEMICAL OR TRADE NAME (print or type) Tba 1 -� <br /> uL�urztC_ C1 X11 <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOT FI- ��}L ' <br /> 40 CFR 355, APPENDIX A A3J CATION UNDER 42 U.S.C. Section 9603(a) K'4 <br /> PH 12? <br /> LIQUID INSGAS PI63SIOALDSTAT LIQUIDELEAS GAS hUANi1TY RELEASED A�( „tyle,; <br /> uu `Y GAt�S1rJS LI '"✓�_Y'��Y✓��'(('' <br /> L_jENVIRONMENTAL CONTAMINATION TiME1OFRELEASE DURATION OOF RELEASE <br /> ❑AIR ❑WATER ❑GROUNDQOTHER �y•aL� DAYS `HOURS—MIN <br /> ANTA Nw Pr51 F To PI"c2VrLT TzmmR1�AL - SHEAIR -Z.7-^ VPSC EZE OAE'`SSG 'TR'12TEO CVA - — 1Z t�SO �6 AltJ <br /> Succi 1_ trt c 9: Q Z9 I . P@JtMAKFvT PF9ArizIs PzNiAr.. <br /> KNOWN OR ANTICIPATED HEALTH EFFECTS (Use the comments section for addition information) <br /> ACUTE OR IMMEDIATE(explain)AcID-TS T SV-uA A S-HC.S <br /> ❑ CHRONIC OR DELAYED(explain) AKNLPU L l� 1 NCESCEn 0 0, (rS t H LED <br /> ❑ NOTKNOM (explain) <br /> ADVICE REGARDING MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> T. ASH <br /> T C P m <br /> A 2gS, CV Cg1A C�AtJ UJATFIZ crpR A NLt N1MVM of (S <br /> �( Mira TE S E!`j� MEOI CRL At2C. • _ <br /> COMMENTS (INDICATESECTION (A-G)AND ITEM WITH COMMENTS ORADDITIONAL INFORMATION) - <br /> PA'P.'t' 4 ,l E E.- 6ROF3ZE0 "T MA <br /> EP t G S4 T <br /> T tF Pkiz-10 wosq, 0 1 r U LdtTM <br /> GPM. p1c SEXC�NnV14•r <br /> C-0 TAtSJMENT UNTIL- T t< R- E02 (!3 PROC£Ss• <br /> CERTIFICATION: I certify under penalty of law that l have personally examined and tam familiar with the information <br /> submitted and believe the submitted infomlatlon is true,accurate,and complete. I w 'll <br /> REPORTING FACILITY REPRESENTATIVE (pmt or type) AJ 0 <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIVE <br />