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THIS FORM PROVIDES <br />GUIDANCE FOR INITIAL NOTIFICATION <br />TIMS FORM PROVIDES GTIDANCE, FOR INI"I'IAL NOTIFICAT ION <br />ENJER("YENCY PLANNING AND COMMUNITY RIGHT -TO -KNOW ACT <br />SECTION 304 Rl,:,'IIOR'I'IN(,T FORM <br />Reporting Nuinber 850/413-9911 <br />1. General Inibrination SARA LOG # <br />A. Tinic,'Dalc <br />B. Repolied by (Nallielcoinpany) <br />C. C6n" Ine, f, c"i­,,"4­')"i'i (1, f, 1 ,3 a6o, %'r,e ), ................. .................................................................................................. <br />................................................................................................................................................................................................................. <br />................................................................................................................................................................................................................................................................... <br />N 6,iii rwr <br />.................................................................................................................................................................................. <br />2. Release Infoiwation <br />A. substance(s) Involved, <br />13 Releaw Medhim. Air Water ........................ (surface/ground) Land ........................ <br />C. E'ventTennin"ned! Yes . A �6 <br />kelease Began Ended DUration <br />D_ Qumfity Released <br />1`11S Release: Yes 12""' �C� o <br />3. Is this a Reportable Incident/E"niergency under Section 304? <br />4. Incident Description: <br />5. ActionTaken to Respond or Contain: <br />6. Potential Health frisk (11'knoNvii or anticipated) <br />A. Off-site <br />B. fiijunes: R� ................................ . I ......................... 111iiaMi"iiibei . .......................................................e case Ike <br />Non -Release Relatcd/Nuiiib ' ............................................................................... <br />7- Reeoniniended Proteetive Actions (Where, Appropriate, Advise Regarding Attention <br />Necessary for Exposal Individuals) <br />S. Agencies Notificd by Injusta <br />A. County IAl. D. State DEP <br />I3. Local 1,.D. F. Other <br />C. Local l",nvironniontal <br />9. Eniergency Assistance Regueste : Ycs/Noe 11' Yes: <br />A. Local F_D_ - ocl Health <br />B. Colultv EA/I• f'. su"Ito DEP <br />C. Local Environmental 6. Other <br />D_ Local Law Enf. <br />10. <br />)-Explain <br />Reason for Not Immediately Repelling the Incident ..................................................................................................................... <br />............... ............... ............... <br />11. Njcs.qtg Received Bv. Name Time Dale <br />THIS DOES NOTFITFILLTHE, REQUIRENIENTS FOR A FOI,,IONV-IJP REPOKI a <br />Indian River County Emergency Plan for Hazardous Materials Page 34 <br />