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12-05-2006 13:58 Freo-OES HQ SA'4 NTO W/C 916-845-8910 T-574 P.001/001 F-942 <br /> GOVERNOR'S OFFICE OF EMIftENCY SERVICES <br /> Hazardous Materials Spill Report <br /> DATr 12/W12006 RECEIVED BY: CONTROLM <br /> TIME: 1348 OES- Courtland Ellis CES- 06-7193 <br /> OSPR- NRC- <br /> l.a. PERSON NOTIFYING GOVERNOR'S OES: r <br /> 2. AGENCY: 33. P 4.Ext: <br /> Valley Pacific Petroleum <br /> Services <br /> I.b. PERSON REPORTING SPH,L Of different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4,Ext: S.PAG/CELL: <br /> z. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY;a=< Amount Measure c.TYPE: d.OTIIER: <br /> 1.DIESEL = 4 Gal(s) PETROLEUM <br /> 2. <br /> 3. _ <br /> e.DESCRIPTION: leak at the nozzle caused the spill <br /> f.CONTAINED: g.WATER INVOLVED: h.WATERWAY: i.DRINICIN'G WATER IMPACTED <br /> Ycs No No <br /> 3. a.INCIDENT LOCATION: 3550 south Hwy 99 <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Stockton San Joaquin County 95206 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE; 12/05/2006 b. TIME (mifirery):1000 C SITE: Service Station <br /> d. INJURIES# e.FATALS#: L EVACS#: g.CLEANUP BY: <br /> 0 0 0 Reporting Party <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> Ia.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADMIN.AGENCY: Sen Jouquin County Emergency Services e.SEC.AGENCY: <br /> f. NOTIFICATION LIST: DOG Unit. RWQCB Unit: 56 <br /> {�InNCUPn V`I::SFwR r AH�A.e. <br /> []POO D&.AD u_OSI IA <br /> L•J AFG-0SPR rLrJ AIR RESOURCES oD L I Doc L I LANDS I_ PARKS k Rhc L I USDDI <br /> Np�J OTSC Cn�TRnNS uR PARKS LJ DES KASMATUNIT L PUC LI OTHER <br /> L^ RWQCB L_ Mr, I.I GMSA -1 OPS PLANS UNIT L]SPM <br /> Cd NS EPA L OOASPALCOM L I FEMA LJ OBS no LJ USMMS <br />