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1129 So. Sacramento Street <br /> SHOLZ Call Box 241002, Lodi, CA 95241 <br /> RUBBER COMPANY,INC. Telephone (209) 366-7171 / FAX (209) 368-3246 <br /> TOLL FREE / 800-285-1600 / FAX 800-756-9998 <br /> EMERGENCY INCIDENT REPORT <br /> 1. Date 2. Time of Incident 3. Company Name <br /> 4. Address 5. Phone 6. <br /> 7. Location of Incident <br /> (explain exact location within the facility) <br /> 8. Extent of Emergency <br /> (explain or describe the situation) <br /> 9. Type of Incident: _Fire Fire/Explosion _Chemical Spill <br /> _Chemical Release into air _Occupational Accident <br /> 10.Cause of Emergency: _Storage Tank or Drum Leak _Process Release/Spill <br /> _Fire _Explosion _Other <br /> (explain) <br /> 11. Identification of Hazardous Material: Shipping Name UN or NA Number <br /> Chemical Name Label Information <br /> Trade Name Other <br /> Physical Description of Material: _Solid _Gas _Granule _Infectious <br /> _Liquid _Powder _Radioactive <br /> 12. If material has run off site: explain amount and location: (If yes, make all required notifications) <br /> _NO _YES <br /> 13. Environment Affected: _Storage Area(s) —Roadway(Public) _Bay/Ocean <br /> _Agriculture Land _Facility Bldgs _Unimp Shoulder <br /> _Coastal Beach _Air Release _Parking Areas <br /> _EnteredSewer(s) —Lake/Stream _Irrigation Water <br /> _Roadway(private) _Entered Storm Drain(s) <br /> _Threat to environment/wildlife: (explain) <br /> 14. Health: Exposure to Employees: Employees Injured: <br /> YES_ NO_ Number_ YES_ NO Number_ <br /> Exposure to Public: Public Injured: <br /> YES_ NO Number_ YES_ NO Number_ <br /> Medical Attention: YES_ NO_ Hospitalized: YES_ NO_ <br /> l5. Evacuation Necessary: YES_ NO—Number staff evacuated from onsite sources <br /> Number evacuated from onsite sources(if known) <br /> Names: Staff Exposed/Injured <br /> Hospital(s) Transported to <br /> Describe Injuries or Exposure (symptoms) <br /> 16. Agencies you have notified: _CHP _Regional Water Board _State Health <br /> _Fire _Sewer District _Air Pollution Control <br /> _CAL Trans _CAL Fish & Game —EPA/Coast Guard <br /> _Police _County Health _Other <br /> 17. Actions Taken to Control Problem: <br /> 18. Person in Charge <br /> 19. Name of Reporter 20. Phone Number <br />