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O,.p4u(N• p SAN JOAQUIN COUNTY-OFFICE OF EMERGENCY SERVICES REVIEW <br /> Q` HAZARDOUS MATERIALS DIVISION <br /> 222 East Weber Avenue,Room 610A, Stockton, CA 95202 DATA ENTRY <br /> Telephone(209)468-3969 Darla Johnson <br /> HAZARDOUS MATERIALS INCIDENT REPORT <br /> DATE REPORT TAKEN BY TIME REPORTED TIME ON SCENE INCIDENT NUMBER <br /> 5/27/96 M Parissi 1430 IR-00213 <br /> REPORTING PARTY/ADDRESS TELEPHONE NO. <br /> Stockton Fire Dept 209-937-8021 <br /> INCIDENT LOCATION ADDRESS CITY ZIP CODE <br /> 1905 N Broadway Stockton 95205 <br /> REPORTING INFORMATION FIRE DISTRICT <br /> 80 Gallon Lorsban Release aWester�FarmServic - 1905 N Broadway, Stockton. Incident occurred at Stockton <br /> approx 1130. WEATHER <br /> Clear <br /> RESPONSIBLE PARTY/ADDRESS TELEPHONE# <br /> Western Farm Service, Inc- 1905 N Broadway, Stockton 209-547-2600 <br /> RESPONSIBLE PARTY REPRESENTATIVE/OWNER TELEPHONE# <br /> Steve Clements- Safety Officer 209-547-2600 <br /> INCIDENT TYPE <br /> Mobile Equipment Release <br /> PROPERTY INVOLVED <br /> Private-Western Farm Release <br /> AREA IMPACTED CONTAMINATION <br /> Commercial Soil <br /> EVACUATION INJURIES <br /> No No <br /> VEHICLE(S)INVOLVED VEHICLE LICENSE NUMBER(S) VEHICLE OWNER(S) <br /> Yes-Forklift&Tagalong N/A I Western Farm Service <br /> SHIPPER'S NAME TELEPHONE# CARRIER'S NAME TELEPHONE# <br /> Western Farm Service 209-547-2600 Western Farm Service 209-547-2600 <br /> 1.CHEMICAL NAME TRADE NAME/MANUFACTURER <br /> Chlorpyrifos I Lorsban 4E <br /> CAS# DOT# DOT HAZARD CLASS PHYSICAL DESCRIPTION OF MATERIAL RELEASED <br /> 2921-88-2 2783 9 1 Liquid Pesticide Solution: 1/2 Gal of Lorsban 4E per 100 Gal <br /> IDENTIFICATION DETERMINED BY <br /> Company Rep <br /> CONTAINER TYPE CONTAINER CAPACITY CONTAINER MATERIAL QUANTITY RELEASED QUANTITY REMANNG IN CONTAINER <br /> Tank 300 Gallons Stainless Steel 80 Gallons 100 Gallons <br /> 2.CHEMICAL NAME TRADE NAME/MANUFACTURER <br /> CAS# DOT# DOT HAZARD CLASS PHYSICAL DESCRIPTION OF MATERIAL RELEASED <br /> IDENTIFICATION DETERMINED BY <br /> CONTAINER TYPE CONTAINER CAPACITY CONTAINER MATERIAL QUANTITY RELEASED QUANTITY REMAINING IN CONTAINER <br /> 3.CHEMICAL NAME TRADE NAME/MANUFACTURER <br /> CAS# DOT# 00T HAZARD CLASS PHYSICAL DESCRIPTION OF MATERIAL RELEASED <br /> IDENTIFICATION DETERMINED BY <br /> CONTAINER TYPE CONTAINER CAPACITY CONTAINER MATERIAL QUANTITY RELEASED QUANTITY REMAINING IN CONTAINER <br /> Page 1 HMIR COMP REV 3/9216 <br />