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From:Cal EMA (State Warning Center) 9168458910 12/30/2010 09:25 #333 P.001/001 <br />California Emergency Management A a <br />9 Y 9 9, 4 <br />Hazardous Materials Spill Repo <br />DATE: 12/30/2010 RECEIVED BY: CONTROL#: <br />TIME: 0915 Cal EMA - Courtland Ellis Cal EMA - 10-7970 1 <br />OSPR- NRC- <br /> <br /> <br /> <br /> <br /> : <br />2. SUBSTANCE TYPE: <br />2. a. SUBSTANCE: b.QTY:>=< Amount Measure c. TYPE: d. OTHER: <br />1. Diesel = 80-100 Gal(s) PETROLEUM <br />2. _ <br />3. _ <br />C. DESCRIP'T'ION: During fueling of a customers tank incorrect calculations caused on over flow <br />f. CONTAINED: g. WATER h. WATERWAY: i.DRI1VKING WATER IMPACTED <br />INVOLVED: <br />Yes No No <br />j. KNOWN IMPACT None <br />3. a. INCIDENT LOCATION: 3932 Newton Rd <br />b. CITY: <br />c. COUNTY: <br />d. ZIP: <br />Stockton <br />San Joaquin County <br />4. INCIDENT DESCRIPTION: <br />RWQCB Unit: 5B <br />a. DATE: <br />b. TIME (Military): <br />C. SITE: <br />d. CAUSE <br />12/2812010 <br />2220 <br />MerchanbBusiness <br />Human Error <br />C. INJURIES <br />f. FATALITY <br />g. EVACUATION <br />h. CLEAN'13'11 BY: <br />❑ CO/WP <br />® RWQCB ❑ CDF <br />-------------------------------- <br />Responsible Party <br /> <br /> <br /> <br /> <br /> <br />6. NOTIFICATION INFORMATION: <br />k. ON SCENE: b. OTHER ON SCENE: c. OTHER NOTIFIED: <br />d. ADMIN. AGENCY: San Joaquin County Emergency e. SEC. AGENCY: <br />Services <br />E ADDITIONAL COUNTY: <br />g. ADMIN. AGENCY: <br />h. NOTIFICATION LIST: <br />DOG Unit: <br />RWQCB Unit: 5B <br />® AA/CUPA ® USF WS <br />❑ CDPH-D.O. <br />❑ FEMA ❑ Cal EMAREG <br />❑ un mw ❑ OnMR <br />® DFG-OSPR ❑ Am RESOURCES BD <br />❑ DOO <br />❑ FOOD & AO ❑ OSHA <br />❑ USce <br />®DISC ❑ CALTRANS <br />❑ DPR <br />❑ LANDS ❑ PARKS &REC <br />❑ CO/WP <br />® RWQCB ❑ CDF <br />❑ EB PARKS <br />❑ Cal EMAFrAZMATUTr ❑ PUC <br />❑ C./Mth <br />® US EPA ❑ COASTAL COM <br />❑ EMSA <br />❑ Cal EMA PLANS UNIT ❑ SFM <br />® CO/Elath <br />CONT- IDEl1'TTAL, <br />REMARKS: <br />%Varning.c-enter al,es.ce.gov; R9_RRCCa F.YA.GUV; UTSC.kR gmr+l7.cona <br />