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07-11-2008 09:56 From-OES HQ SACRAMENTO W/C 916-845-8910 T-998 P.001/001 F-662 <br />GOVERNOR'SWICE OF EMERGENCY <br />SERVICES <br />Hazardous Materials Spill Report <br />DATE: 07/11/2005 RECEIVED BY: CONTROLM <br />TIME: 0939 OES - Courtland Ellis OFS - 08-5082 <br />OSPR - NRC - <br /> <br /> <br /> <br /> <br /> <br />I.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•>-K Amount Pleasure c. TYPE: d. OTHER: <br />1. Ammonia = 7.5 Lbs, VAPOR <br />2. <br />3. <br />e. DESCRIPTION; A site glass gasket leaked and cauied this vapor release <br />L CONTAINED: g. WATER INVOLVED: h. WATERWAY: i. DRINKING WATER TMPACTED <br />Yes No No <br />3. a. INCIDENT LOCATION: 17000 East Highway 120 <br />b, CITY, c. COUNTY: d. IIP: <br />Ripon San Joaquin County 95366 <br />4. INCTDENT DESCRIPTION: <br />a. DATE,. 07/11/2005 b. TIME (Military). -0915 C. SITE: Other <br />d. TNJURIES# e. FATALS #: f. EVACS #: g. CLEANUP BY: <br />0 0 0 Unknown <br /> <br /> <br /> <br /> <br /> <br /> <br />6. NOTIFICATION INFORMATION: <br />in. ON SCENE: b. OTHER ON SCENE: c. OTHER NOTIFIED: <br />d. ADMIN. AGENCY: Scsn Jagquin Caunry Emcrgrncy Services e. SEC. AGENCY: <br />f. NOTIFICATION LIST: DOC !Jail: <br />RWOCB Unit- 5a <br />ED Y AA/CUPA <br />L''�1 DPG-OSPR <br />L5F <br />P 4YS -C� DHS -D.0, <br />.__k AIK OSOLRCES 6D lr -� DOG <br />_J FQ-D - AG <br />L LANDS <br />j .I OSHA <br />LJ PAHIi,.S & RY_C <br />I LiSCG <br />l LJSDOI <br />pT�C <br />^�� CALTRANS I` I ES PAkKS <br />!r Cpf SMSA <br />El DES HA7-NIATuNrr <br />E MS PIANS UN11' <br />Q PUC <br />� IF - <br />l_� OTHER <br />RWQC1 <br />E US F;PA <br />rL._I <br />1 - COASTAL COM l FEMA <br />17 DES REG <br />L_.I USMMS <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />