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EMERGENCY RELEASE FOLLOW-UP NOTICE REPORTING FORM <br /> BUSINWS NAME FACILITY EMERGENCY CONTACT 8 PHONE NUMBER <br /> Corn Products, Stockton Plal Roger Hoffdahl (2091 982 1920 <br /> INCIDENT MO DAY YR I TIME OES <br /> DATE 01 (OPEIFIEDc3 (use24trtime) CONTROLNO. I AAA/ <br /> INCIDENT ADDRES§ LOCATIQNCIN/COMMUNITY COUNTY ZIP <br /> 1021 lndustrial Drive tockton San Joaquin 95206 <br /> CHEMICAL OR TRADE NAME (print or type)Hydrochloric AciCAS Number <br /> Solution 20 Be 32% in bulk Stora e tank. 7647-01-0 <br /> CHECK IF CHEMICAL IS LISTED IN CHECK IF RELEASE REQUIRES NOTIFI- <br /> 40 CFR 355, APPENDIX A NOCATION UNDER 42 U.S.C. Section 9603(a)QUANTITYR <br /> ❑ <br /> PHYSCAL ELEAED RELEASED <br /> ❑1 O IDTATE.,OOAD PHYSICAL(QUID INE❑GAS ❑SO DSTATE LVLIQUIDS <br /> ❑ GAS xT00 Alakho UI <br /> ENVIRONMENTAL CONTAMINATION TIMEOFRELEASE IDURATION OF RELEASE <br /> DAIR EIWATER ❑GROUNDE]OTHER QQ _DAYS OURS. MINU <br /> ACTSON TA llt down upon discovery. Line leak, process SUDPly line <br /> for pH adjustment. Total estimated loss agproximately <br /> dilute 4.0 Be or 30-35 <br /> P <br /> IPATED HEALTH EFFECTS (Use the comments section for addition information) <br /> R IMMEDIATE(explain) <br /> OR DELAYED(explain) <br /> WN(explain) <br /> NG MEDICAL ATTENTION NECESSARY FOR EXPOSED INDIVIDUALS <br /> COMMENTS (INDICATE SECTION (A-G)AND ITEM WITH COMMENTS ORADDITIONAL INFORMATION) <br /> Non-emergency notification made to the City of Stockton MUD, San <br /> Joaquin County CUPA Environmental Health Dept. and California Stat <br /> Garrett Backus on site @ 1715. <br /> CERTIFICATION: I certify under penalty of law that I have personally examined and I am familiar with the Information <br /> submitted and befieve the submitted information is true,amrate,and complete. <br /> REPORTING FACIUTY REPRESENTATIVE (print ortype) Ro er W Hof <br /> SIGNATURE OF REPORTING FACILITY REPRESENTATIV UA j V I PATE: " <br /> rN <br /> COP <br /> I n C.£Pp,_C. <br />