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03-01-2004 14:32 From-OES HQ Sk"IENTO W/C 916-845-8910 T-409 P.001/001 F-937 <br /> �v��Rivvrc's UI-FICE OF— .,ERGENCY SERVICES <br /> ..,... Hazardous Materials Spill Deport <br /> DATE: 03/01/2004 <br /> <br /> <br /> <br /> <br /> <br /> � 1-209-468-3969 <br /> I.b. PERSON REPORTING SPILT,(If different froth above); <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext; S.PAG/CELL- <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:>=< Amount Measure <br /> 1. Gasoline 3 c.TYPE: d.OTHER., <br /> Gal(s) PETROLEUM <br /> 2. <br /> 3. <br /> C. DESCRIPTION; Bduipment failure caused this release. <br /> f. CONTAINED; g. WATER INVOLVED; h.WATERWAY: i.DRINKING WATER IMPACTED <br /> Yes No <br /> 3- a.INCIDENT LOCATION: 500 W. Hos <br /> <br /> <br /> <br /> ess <br /> d. INJURIES# e.FATAL$#: f EVACS#: <br /> p 0 0 g• CLEANUP 8Y: <br /> Contractor <br /> ,Sameas#T."-PERSON N IIFYING- OE t <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> Chuck Peek San Joaquin Co. Hospital 209-468-6000 <br /> e.MAIL,ADDRESS: f.CITY: g. STATE: h.ZIP: <br /> S00 W. Hospital Rd. French Camp CA 95231 <br /> 6 NOTIFICATION INFORMATION: <br /> la.ON SCENE. b.OTHER ON SCENE: c.OTHER NOTIFIED. <br /> Co Health, Co CIES,Fire Dept., Sheriff <br /> Ofc. <br /> d.ADMIN.AGENCY: San Joaquin County Emergency services e.SEC.AGENCY. <br /> f.NOTIFICATION LIST: DOG Unit: RWQCB Unit: SB <br /> _�AAICUPA U IISPWS L i OHS-D_O. FOOD&nG .�OSHA <br /> �_I USCG <br /> L.'DPc.asrR ��AIR RESOURCES BDL DOG 1. I LANDS PARKS&REC <br /> USDOI <br /> I PTSC CALTRANS <br /> I' r I GL•S HAZMATUNIT n <br /> UC <br /> _ .J L 22 PARKS ID (J P <br /> rr ,, ,�OTrmR <br /> �_.._I AwQCB r�CDP C IMSA a DES PLANS UNrr I�SPM <br /> 1_' LAS EPA !�COASTAL CONI Li FEMA DES P.FG <br /> .J USMMS <br /> L <br />