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Road Dist. HAZARDOUS MATERIALS <br /> Fire Dist. NOTIFICATION FORM Case x <br /> Class --- <br /> Zdy�,� Level _ <br /> A. Date: l 10 SO <br /> Present Time: Incident Time: <br /> B. Reported by: <br /> Home Telephone: <br /> C. Home Address: / <br /> Street name do Number / <br /> City Zip <br /> D. Calling From: ?-2 2 4 . /✓Q� ZCJ� Z1// <br /> Telephone: <br /> Address City <br /> E. Type of Incident: [ ] Explosion [ ] Spill [ J Leak [ ] Crash <br /> [ ] Irritant �Cj, Abandon/dumped [ ] Other: [ ] Fire <br /> F. What Happened: S�� �, 10 <br /> c <br /> G. Number of Injuries: ��By Material: Type: <br /> ^� EXACT LOCATION Address•A1759' <br /> fess <br /> , 11 <br /> H. Name of Business: ✓�i`�U�,� <br /> I. Type of Structure: <br /> J. VEHICLE(s) ; I.D.*: Lic.*: �N�C. <br /> State: <br /> K. Environment Affected: ' Soil: <br /> [ ] <br /> [ j <br /> Water: Road: <br /> [ ] Air: <br /> L. _ Population: [ ] None [ ] Urban [ ] Rural Business <br /> _ _ � [ ] Industrial <br /> M. Weather: Wind mph :ram o 0 <br /> --—p Temp__ Humidity X Other_ <br /> N. Evacuation/Shelter Action: <br /> When: <br /> IDENTIFICATION OF MATERIAL _.. <br /> 0. Substance Form: [ ] Solid [ ] Power [ ] Gas <br /> _ dX] Liquid [ ] Granule <br /> P. Type of Container: ,� N.� ( � <br /> d �GtMS' Condition: (�ad <br /> Q. Quantity of Material: � S 5^ en, W2o/111,5 i, 4 <br /> fWl <br /> R. Trade Name: UAIX Chemical Name: UA/4 <br /> S• UN do EPA Number• �/4- Hazard Class: <br /> T. Placard Description: Placard No. : <br /> U. Manufacturer's Name: Telephone: (_) <br /> V. Shipper's Name: Telephone: ( ) <br /> W. Carrier's. Name: <br /> Telephone: ( ) <br /> X. Consignee Name. <br /> Telephone: ( ) <br />