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10-25-2007 22:08 From-OES HQ SACRAMENTO W/C 916-845-8910 T-176 P.002/002 F-732 <br /> • ►,..,��o vrriut vt- =RGENCY SERVICES <br /> Hazardous Mater Spill Report <br /> DATE: 10/25/2007 RECEIVED BY: CONTRTW TIME: 2027 OE:S- Amanda Loveless OES- 0-::::] OSPR- <br /> 1-b. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: Q.Ext: 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: h.QTY:>=< 4mount Measure <br /> 1.Anhydrous Ammonia = 25 Lbs, <br /> c.TYPE: d.OTHER: <br /> 2. _ <br /> VAPOR <br /> 3. <br /> e.DESCRIPTION: Leak on roof from refrigeration system. <br /> f.CONTAINED: g.WATER INVOLVED: 11.WATERWAY: i.DRINKING WATER IMPACTED <br /> Yes No <br /> No <br /> 3. a.INCIDENT]LOCATION: 16888 McKinley Avc <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Lathrop San Joaquin County 95330 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: 10/25/2007 b. TIME (Miiita y):2000 C.SITE: Other <br /> d. INJURIES# e.FATALS#: f. #:EVACS <br /> 0 0 0 g.CLEANUP BY: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> !a.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADMIN.AGENCY; San Joaquin County Emergoncy SaMcCS e,SEC.AGENCY: <br /> f NOTIFICATION LIST: DOG Unit= (� RWQCB Unii: 5B <br /> LV AA/CUPA n�USFWS LJ PHS-DLO. El--- <br /> FOOD R AG I�.JI OSHA I�TJ3CC <br /> AFC•03PR I. .I AIR MOURCIM BD I <br /> DOG rFJ LANDS LTJ- FARM&RHC El <br /> ff��11 me IUI CALTRANS u PB PARKS E ORS HAZMATUNIT I J FUC J1 USAO[ <br /> ����V1 RWQCB t.J11 CDP rr0 EMSpF1 OES IJ OTHPR <br /> I JI US 9PA �J COASTAL CUM U FLjMA r,O PLANS UNii U SSMC <br />