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08-27-2008 14:28 From-DES HQ SACRAMENTO W/C 916-845-8910 T-089 P.001/001 F-825 <br /> :��• GOVERNOR'S Of E OF EMERMe <br /> ��. SERVICES <br /> Aft <br /> Hazardous Materials Spill <br /> DATE: 08/27/2008 RECEIVED BY: CONTROLM <br /> TIME: 1416 OES. Bob Mcrae OES- 08-6254 ,. <br /> OSPR- INRC- <br /> G/c <br /> I.aPERSON'NOTIFYING GOVERNOR'S OES: --':'j1. NAME: 2. AGENCY: 3. PRONE#: 4.Ext: 5.PA <br /> Flying J <br /> I.b. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PRONE#: 4.Ext: 5.PAG/CELL: <br /> 2. SUI3STANCE TYPE: <br /> A <br /> 2.a.SUBSTANCE: b.QTY:>r,< mount Measare c.TYPE: d.OTHER: <br /> 1.Antifreeze = 1/2 GBI(5) CHEMICAL <br /> 2. <br /> 3. _ <br /> e.DESCRIPTION: A customer spilled the autiffeeze at the service station <br /> f.CONTAINED: g.WATER.INVOLVED: h.WATERWAY: i.DRINKING WATER IMPACTED <br /> Yes No No <br /> 3. a.INCIDENT LOCATION: 1501 Jacl.�tar Rd. <br /> b.CITY_ c.COUNTY: d• ': <br /> RipRn San Joaquin County <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE:08/27/2008 b. TIME (Mllrrary).1319 c.SITE: Service Station <br /> d. INJURIES# e.FATALS#: f.EVACS#: g.CLEANUP BY: <br /> 0 0 0 <br /> Unknown <br /> Sam®as#1."PERSQN NOTIFYIN_G OES"; <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> Fire Dept_ <br /> d,ADMIN.AGENCY: San.toaquin County Ern rgencY Smica6 e.SEC.AGENCY: <br /> L NOTIFICATION LIST: DOG Unit: RWQCB Unit. 513 <br /> ��!`��AA/C[7PA ��� USf WS ❑�oHS•D.O. ❑POGD&w0 r��OSHq L��LSCO <br /> 2p �OFG.OSPR ❑AM RBSOURCPS BD LJ D00 LANDS ❑PARKS&RBC Iptic r_.I OTHef <br /> OTSC ❑CALTRANS ❑EB PARKS ❑OES KAZMATUNT1 ❑SFM I., OTtiRR <br /> pIpJ�RWOCB ❑CDP ❑BMSA ❑OUSPLANS UNIT u <br /> t U US SPA ❑COASTAL.COM ❑PEMA ❑OBS REG ❑USMMS <br /> CAAk <br /> lld� fp <br /> IMA <br /> ,)kk L,,-r� P �,,- hW b amt-�e� = t <br />