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Ercm:Cal EMA (State Warning Center) 9168458910 12/14/2009 07:08 90 P.001/001 <br /> 4 <br /> California Emergency Management en�y.: <br /> Hazardous Materials Spill Report J 'Xi <br /> DATE: 12/14/2009 RECEIVED BY: CONTROL#: <br /> TIME: 0656 Cal EMA- Bob Mcrae Cal EMA- 09-8315 <br /> OSPR- NRC- <br /> La. PERSON NOTIFYING Cal ENIA: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CELL: tl, <br /> Front Range Environmental <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:>=< Amouni Measure e.TYPE: d.OTHER: <br /> 1. Water Based Paint - 30 Gal(s) CHEMICAL <br /> 2. <br /> 3. _ <br /> e.i'sFSCIUPTION: A container of paint fell of a pallet and spilled ars the floor. <br /> f CONTAINED: g.WATER h.WATERWAY: i.DRINKING WATER IMPACTED <br /> INVOLVED: <br /> Yes No Pio <br /> j. KNOWN IMPACT None <br /> 3. a.INCIDENT LOCATION: 3010 W. Grantline Rd. <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Tracy San Joaquin County <br /> 4.INCIDENT DESCRIl'TION: <br /> a.DATE: b. TIME (Military): C.SITE: d. CAUSE <br /> 12/11/2009 1300 Other Human Error <br /> e. INJURIES f.1+ATAI.k Iff g. EVACUATION 'n.CLk:ANI,P s'rdY: <br /> ..................... Contractor Contractor <br /> <br /> <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> Ia. ON SCENE: b. OTHER ON SCENE: c. OTHER NOTIFIED: <br /> d.ADMIN.AGENCY: San Joaquin County ErnergenC•i e.SEC.AGENCY: <br /> Services <br /> f. ADDITIONAL COUNTY: g.ADMEN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RIVQCB Unit: 5B <br /> ®AA/CUPA ®USFWS ❑CDPH-D O ❑FEMA ❑Cal EMA REG ❑USMMS ❑OTHER <br /> ®DFG-OSPP. ❑ATR RESOURCES BD ❑DOG ❑FOOD&AG ❑OSHA ❑USCG <br /> ®DTSC ❑CALTRANS ❑DPR ❑LANDS ❑PARKS&REC ❑Co/WP <br /> ®RWQCB ❑CDF ❑EB PARKS ❑Cal EMA HAZMATUNTf❑PUC ❑Co/Hlth <br /> ®US EPA ❑COASTAL COM ❑EMSA EIC-1 EMA PLANS UNIT ❑SFM ❑Co/E-filth <br /> YS%arniag.cr:ntcr�Fe%oes.ca.goi;R.u_XR.L'Cx?k:PA.G�?�';i>7':St'.F.}Z,'rt)tma:l.cfertt <br /> c W� <br />