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iu~~~~ii~tin~«iu <br />' COLORADO DEPARTMENT OF HEALTH <br />EMERGENCY MANAGEMENT UNIT (EMU) <br />INCIDENT REPORT • <br />Reporting Party. (J Representigg: Telephone Number: <br /> q- - <br />Incident ported: Incide t Occurred: <br />Date: Time: ~ Dale: ~ Time: ~ ~~ <br />Indial Caller (Placing wll to Reporting Party): Re <br />pre <br />se <br />nting: Telephone Number: <br /> // <br />~~ <br />~~ <br />' <br />~^ <br />~ <br />Name: L(A,WJV~ 1`~^ 1~. \L. <br />Incident Location: <br />~~ ~ J <br />Type of Accident (Check all applicabl <br />Medical Emergency Injuries w Fatalities Radiation Accident <br />Natural Disaster Release to the Air Chemical Spill <br />Fire or 6rplosion HAZMAT Complaint Fuel Spill <br /> <br />specify: <br />-k.c.l~~d d.~.~ -~o .~_. <br />• ~ ,. ~ s r n ~,. <br />Air Soil Structures or Facilities <br />Name of Nearest Water Body Ground Waler Public Water Supply <br />People Not Applicable <br />Materials Involved: Amount or Rate of Release: <br />A • ~U 3GO - SCE <br />Ptrysical State of Contaminants: <br />Gaseous: Liquid: ~--Solid <br />