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01-11-2007 17:25 From-OES NQ SA"IMENTO W/C 916-845-8910 T-890 P.001/001 F-413 <br /> GOVERNOR'S OFFICE OF&RGENCY SERVICES <br /> Hazardous Materials Spill Report <br /> N. <br /> DATE: 01/11/2007 RECEIVED BY: CONTROL#: <br /> TIME: 1714 OES• Courtland Ellis OES- 07-0229 <br /> OSPR- NRC- <br /> 1.a. PERSON NOTIFYING GOVERNOR'S OES: <br /> 1. N <br /> 2. AGENCY: 3. P ONE#: 4.Ext <br /> Valley Pacific Petroleum <br /> Services 1 Z <br /> Lb. PERSON REPORTING SPILL(if different from above): <br /> 1. NAME; 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/CET :' <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTV:a=< Amount hlraxnre c.TYPE: d.OTHER: <br /> 1.Diesel - 25 Gal(s) PETROLEUM <br /> 2. <br /> 3. _ <br /> e.DESCRIPTION! Customer left the hold open latch open and caused the spill <br /> f.CONTAINED: g.WATER INVOLVED: h.WATERWAY: i.DRINKING WATER IMPACTED <br /> Yes No No <br /> 3. a.INCIDENT LOCATION: 3550 S Highway 99 <br /> b.CITY c.COUNTY: d.ZIP: <br /> Stockton San Joaquin County 95206 <br /> 4.INCTDT:NT DESCRIPTION; <br /> a.DATE:01/11/2007 b. TIME (404ary):1430 C.SITE: Other <br /> d. INJURIES# e.FATALS#: f.EVACS#: g.CLEANUP BY; <br /> 0 0 0 Reporting Parry <br /> 6. NOTIFICATION INFORMATION: <br /> �.ON SCENE; b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADMIN.AGENCY: Son Joaquin county Lmergency Services e.SEC.AGENCY; <br /> E NOTIFICATION LIST: DOG Unit: rr II RWQCB Unit: 5B <br /> LJ AAICUPA F^] a USPWS ❑PHS-D.O. P000 k AG ❑OSHA ❑VSCG <br /> ®�f- DFO.OSPR L]Apt ResouRCes BD❑DDG C I LANDS El PARKS&RHc ❑usual <br /> LJ DISC I _In,CALTRANS ORAPAWS �CVNrr ❑ ❑ <br /> ^IOmst(A2MATPUC OTHER <br /> ©RWQCB I_ CDP I.J BMSA LJ OBS PUNS UMT ❑SFM <br /> Lam'1 UI ^ <br /> S FPA ❑COASTAL CO.COM PPMA ❑OHS REG L I VSMMS <br />