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�rom:Cal EMA (State Warning Center) 9168458910 12/11/2009 14:56 #003 P.001/001 <br /> California Emergency Management Agency <br /> Hazardous Materials Spill Report <br /> DATE: 12/11/2009 RECEIVED BY: CONTROL-4: <br /> TIME: 1443 CalEMA- Ruben Rodriguez Cal EMA- 09-8274 <br /> OSPR - NRC - <br /> La. PERSON NOTIFYING Cal E1VIA: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4. Ext: 5.PAG/CELL: <br /> Tracy WalMart 209-836-5786 <br /> Lb. 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:>=< Amount Measure e.TYPE: d.OTHER: <br /> 1. Water Based Paint = 4o G81(s) CIID./1C AL <br /> 2. _ <br /> 3. _ <br /> e.131;5 'II''1'ItJ A fork-lift operator dropped a pallet containing the released material. <br /> f. CONTAINED: g.WATER h.WATERWAY: i.DRL1VKING WATER 111-EPACTED <br /> INVOLVED: <br /> Yes ;\10 <br /> j. KNOWN IMPACT <br /> 3. a.INCIDENT LOCATION: Wal1\4art, 3010 West Grant Line Rd <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Tracy San Joaquin Cowity 95304 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (Military): c.SITE: d. CAUSE <br /> 12/11/2009 1215 Merchant,Business Human Error <br /> e. INJI?RI-Es F. FATALITY g. EVACUATION h,C::€..IVANUP BY: <br /> - <br /> Contractor <br /> K.-------------------------- <br /> <br /> <br /> <br /> <br /> <br /> b. NOTIFICATION INFORMATION: <br /> �. ON SCENE: b. OTHER ON SCENE: c. OTHER NOTIFIED: <br /> d.ADMIN.AGENCY: San Joaquin County e.SEC.AGENCY: <br /> Emergency Services <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RWQCB Unit: 513 <br /> ®AA/CUPA ®USF WS ❑CDPH-D O ❑FEMA ❑Cal EMA REG ❑USMMS ❑OTHER <br /> ®DFG-OSPR ❑AIR RESOURCES BD ❑DOG ❑FOOD&AG ❑OSHA ❑USCG <br /> ®DTSC ❑CALTRANS ❑DPR ❑LANDS ❑PARKS&REC ❑CO/WP <br /> ®RWQCB ❑CDF ❑EB PARKS ❑Cal EMAHAZMATUNTT❑PUC ❑Co/Hlth <br /> ®US EPA ❑COASTAL COM ❑EMSA ❑Cal EMA PLANS UNIT ❑SFM ❑Co/F—Hlth <br /> Yarning.centerf,ci�3es.ca.gov:R9 RFK:fir,1'A.GUV;D'rSC.ER-,4gma11.;om <br /> s� �- <br />