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Frflm:Cal EMA (State Yarning Center) 9168458910 <br />02/11/2010 10:08 <br />California Emergency N.lig_, y� <br />(Hazardous Materials Spill Reo <br />DATE: 02/11/2010 <br />RECEIVED BY: <br />CONTROL -A <br />TIME: 0945 <br />Cal ENlA - Bob Mcrae <br />Cal EMA - 10-1082 <br />OSPP- <br />NRC - <br />1.a. PERSON .NOTIFYIING Cal EMA; <br />L NAME: 2. AGENCY: 3. PHONE#: 4. Ext: 5. PAG/CELL: <br /> Che»ror, <br />1.b. PERSON REPORTING SPILL ¢f different from above): <br />1. NAME: 2. AGENCY: 3. PHONE#: 4. Exit: 5, PAGiCELL: <br />2. SUBSTANCE TYPE: <br />2. a. SUBSTANCE: b.QTY:>=; Amewit mea we c. TYPE: d, OTHER: <br />1. Diesel - i Gal(s) PETIi_OLET_'.\/l <br />2. _ <br />3. _ <br />e. ilFSCIUPTION: A customer spilled diesel at the pump. The diesel spilled into a drain, but remained on the <br />property The fire department and Environmental Health were on scene. A contractor will be <br />recovering the diesel from the drain. <br />L CONTAINED: g. WATER h. WATERWAY: i.DRINKIf1iG WATER h-VLPACTED <br />INVOLVED: <br />Yes No No <br />j. KNOWN IMPACT None <br />3. a. INCIDENT LOCATION: 10858 Trinity Pkwy <br />b. CITY: <br />c. COUNTY: <br />d. ZIP: <br />Stockton <br />San Joaquin County <br />4. INCIDENT DESCRIPTI0117: <br />RvVQCB Unit: 5B <br />a. DATE: <br />b. TEME <br />c. SITE: <br />d. CAUSE <br />02/11 /2010 <br />0025 <br />Service Station <br />Human Error <br />e. I` J(jf2II:S <br />f. FA'i APAIT`Y <br />g. EVACUATION <br />It, CLl<;ANIIP BY: <br />❑ Co/WP <br />® RWQCB ❑ CDF <br />❑ EB PARKS <br />Contractor <br />ta Nb:.- <br />:... <br />.... .. <br />❑ EMSA <br />❑ Cal EMA PLANS UNIT ❑ SFM <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />b. NOTIFICATION INFORtVIATIONY : <br />�. ON SCENE: <br />b. OTHER ON SCENE: <br />c. OTHER NOTIFIED: <br />d. ADMIN. AGENCY: San Joaquin County Emergency e. SEC. AGENCY: <br />Services <br />001/001 <br />.j <br />E ADDITIONAL COUNTY: <br />g. ADMIN. AGENCY: <br />h. NOTIFICATION LIST: <br />DOG Unit: <br />RvVQCB Unit: 5B <br />® AA/CUPA ® USFWS <br />❑ CDPH-D 0 <br />❑ FEMA ❑ Cal EMAREG <br />❑ USMMS ❑ OTHER <br />® DFG-OSPR ❑ AIR RESOURCES BD <br />❑ DOG <br />❑ FOOD & AG ❑ OSHA <br />❑ USCG <br />® DTSC ❑ CALTRAm <br />❑ DPR <br />❑ LANDS ❑ PARKS & REC <br />❑ Co/WP <br />® RWQCB ❑ CDF <br />❑ EB PARKS <br />❑ Cal EMAHA.ZMATUM ❑ PUC <br />❑ Co/Hlth <br />® US EPA ❑ COASTAL COM <br />❑ EMSA <br />❑ Cal EMA PLANS UNIT ❑ SFM <br />❑ Co/E-Mth <br />��arning.rrtteriu�tu:s.c,:a, Ri-RR("Q YA.COff:ItTSC.TnR�a7;maii.cnaaa <br />u �.ffij�, lX Cv �1 v 4 �$� l L 2'i �l <br />