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11-16-2007 12:39 From-OES HQ SAM'�j0 W/C 916-845-8910 T-243 P.002/002 F-671 <br /> c! kJ ; GOVERNOR'S OFFICE OF EME NCY SE <br /> °L# Hazardous.Materialill Rep <br /> a�3 sM94D <br /> �m%u•a xn..xw <br /> DATE: 10/25/2007 RECEIVED BY: CONTROL#: <br /> TIME: 2027 OES- Amanda Loveless OSS- 07-6553 <br /> OSPR- 7NRC <br /> - <br /> <br /> <br /> 1.b, PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY-.— Amounc measure c.TYPE: d.OTHER: <br /> 1.Anhydrous Ammonia = 25 Lbs. VAPOR <br /> 2. _ <br /> 3. - <br /> e.DESCRIPTION: Leak on roof from refrigeration system <br /> f.CONTAINED: g.WATER INVOLVED. h.WATERWAY:• i.DIU MING WATER IMPACTED <br /> Yes No No <br /> 3. a.INCIDENT LOCATION: I6888 McKinley Ave <br /> b.CITY: e.COUNTY: d•ZIP: <br /> Lathrop San Joaquin County 95330 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE:10/25/2007 b. TIME (Mitltary):2000 c.SITE: Orher <br /> d. INJURIES# e.FATALS#: E EVACS#: g.CLEANUP BY: <br /> 0 0 0 Reporting Party <br /> <br /> <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> Ia.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADMIN.AGENCY: San Joaquin County Finageney ServiceS e.SEC.AGENCY: <br /> f.NOTIFICATION LIST: POG Unit•. IIWQCB unit;5B <br /> L'J AArCUPA U UNFws �Lr—III DHS-D,O. U FOOP&AG ❑rII OSIA -��USCG.—_^--- <br /> PFCrOSPR ❑AM RESOURCES API J 000 ❑LANDS __l PARKS&RSC LJ USPOI <br /> OTSC ❑CALTRANS ❑QB PARKS 0 OSS HAZMATUNI T ❑PUC ❑Owlut <br /> �- RWQCB U CF ❑EMSA ❑OBS PLANS UNIT ❑SpM <br /> K-�US SPA ❑COASTAL COM C I FEMA ❑OF--RRC ❑USM:v:S <br />