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From:Cal EMA (State Warning Cer) 9168458910 06/0�f..2010 15:18 #788 P.001/001 <br /> California Emergency Management Agency <br /> Hazardous Materials Spill Repart <br /> DATE: 06/04/2010 RECEIVED BY: CONTROL-#:TIME: 1500 Cal EMA- Charles Bickinella CalEMA- 10-3437nM <br /> DOSPR- NRC - <br /> <br /> <br /> Lb. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PA N j,. <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:>=< Amount Measure c.TYPE: d.OTHER: <br /> 1.Diesel fael < 1 Gal(s) PETROLEL71VI <br /> 2. _ <br /> 3. _ <br /> e.DESf'MPTION: While a driver Was filling the tar-Ac on a truck the nozzle came out and catLsed the release to <br /> concrete. The spill has been cleaned up. <br /> f.CONTAINED: g.WATER h.WATERWAY: i.DRINKING WATER IMPACTED <br /> INVOLVED: <br /> Yes No No <br /> j.KNOWN IMPACT <br /> 3. a.INCIDENT LOCATION: 16888 McKinley Ave <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Lathrop San Joaquin County 95330 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (Military): C.SITE: d. CAUSE <br /> 06/04/2010 1450 Service Station Human Error <br /> e, 11,4J RIES 1 I<. 'T.�.1,1J n. r. 'id:7:1AT143`1 Ia.CLEANUT.13Y: <br /> Reporting Party <br /> .Y� <br /> <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> Ia.ON SCENE: b.OTHER ON SCENE: c. OTHER NOTIFIED: <br /> d.ADM[N.AGENCY: San Joaquin County Emergency e.SEC.AGENCY: <br /> SCrV'IL'C:S <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RtWQCB Unit: 5B <br /> ®AA/CUPA ®USFWS ❑CDPH-D.O. ❑FEMA ❑Cal EMAREG ❑USMMS ❑=Dm <br /> ®DFG-OSPR ❑AIR RESOURCES BD ❑DOG ❑FOOD&AG ❑OSHA ❑USCG <br /> ®DTSC ❑CALIRANS ❑DPR ❑LANDS ❑PARKS&REC ❑Co/WP <br /> ®RWQCB ❑CDF ❑EB PARKS ❑Cal EMAHAZMATONrr❑PUC ❑Co/Mth <br /> ®US EPA ❑COASTAL COM ❑EMSA ❑Cal EMA PLANS UNrr ❑SFM ❑Co/E-Hlth <br /> � <br /> <br /> /) <br />