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U.S. Department of Transportation Hazardous Materials Form Approval OMB No. 2137-0039 Pipeline and Hazardous Materials Safety Administration Incident Report According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 2137-0039. The filling out of this information is mandatory and will take 96 minutes to complete. INSTRUCTIONS: Submit this report to the Information Systems Manager, U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration, Office of Hazardous Materials Safety, DHM-63, Washington, D.C. 20590-0001. If space provided for any item is inadequate, use a seperate sheet of paper, identifying the entry number being completed. Copies of this form and instructions can be obtained from the Office of Hazardous Materials Website at http://hazmat.dot.gov. If you have any questions, you can contact the Hazardous Materials Information Center at 1 -800 -HMR -4922 (1-800-467-4922) or online at http://hazmat.dot.gov. PART I - REPORT TYPE 1. This is to report: ❑® A) A hazardous material incident ❑ B) An undeclared shipment with no release ❑ C) A specification cargo tank 1,000 gallons or greater containing any hazardous materials that (1) received structural damage to the lading retention system or damage that requires repair to a system intended to protect the lading retention system and (2) did not have a release. 2. Indicate whether this is: An initial report ❑ A supplemental (follow-up) report ❑ Additional Pages PART 11- GENERAL INCIDENT INFORMATION 3. Date of Incident: 08/21/2015 4. Time of Incident (use 24-hour time): 00:02 5. Enter National Response Center Report Number (if applicable): N/A 6. If you submitted a report to another Federal DOT agency, enter the agency and report number: NA 7. Location of Incident: City: Stockton County: San Joaquin State: CA ZIP Code (if known): 95205 Street Address/Mile Marker/Yardname/Airport/Body of Water/River Mile 801 Diamond Street Stockton, CA95205 8. Mode of Transportation ❑ Air ❑ Highway ❑® Rail ❑ Water 9. Transportation Phase®❑ In Transit ❑ Loading ❑ Unloading ❑ In Transit Storage 10. Carrier/Reporter Name BNSF Railway Company Street 2500 Lou Menk Drive City Fort Worth State TX ZIP Code 76131-2830 Federal DOT ID Number 281683 Hazmat Registration Number 062615552003XZ 11. Shipper/Offeror Name Tessenderlo Kerley Street 480 South & 260 West City Burley State ID ZIP Code 83318 Waybill/Shipping Paper Unavailable Hazmat Registration Number Unavailable 12. Origin Street Same as shipper (if different from City State ZIP Code shipper address) 13. Destination Street 10724 Energy Street City Hanford State CA ZIP Code 93230 14. Proper Shipping Name of Hazardous Material: CORROSIVE LIQUID, BASIC, INORGANIC, N.O.S. 15. Technical/Trade Name: (METAM SODIUM) 16. Hazardous Class/ 17. Identification 18. Packing 19. Quantity 5 Division: 8 Number: UN3266 Group: 11 Released: Liquid - Gallon (E.g. UN2764, NA 2020) (if applicable) (Include Measurement Units) 20. Was the material shipped as a hazardous waste? ❑ Yes No If yes, provide the EPA Manifest Number: N/A 21. Is this a Toxic by Inhalation (TIH) material? ❑ Yes No If yes, provide the Hazard Zone: N/A 22. Was the material shipped under an Exemption, Approval, or Competent Authority Certificate? ❑ Yes No If yes, provide the Exemption, Approval, or CA number: N/A 23. Was this an undeclared hazardous materials shipment? ❑ Yes ❑® No Form DOT F 5800.1 (01-2004) Page 1 Reproduction of this form is permitted