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09-24-2007 16:11 From-OES HQ SACRAIFNTO W/C 916-845-8910 T-374 P.001/001 F-460 <br /> 0. F-1 �S GOVERNOR'S OFFICE OF EM, AENCY SERVICES <br /> Hazardous Materials Spill FOPort <br /> I:tMr�+l[MN••r+ <br /> /Pm7VV•1M11AA <br /> TE <br /> RECEIVED BY; COIN I <br /> DA : 09/24/2007 <br /> TIlNE: 1547 OES- Amaaida loveless NRC- 0- 83 <br /> OSPR - <br /> l.a. PERSON NOTIFYING GOVERNOR'S OES: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5,PAG/CELL. <br /> <br /> <br /> Lb. PERSON REPORTING SPILL(If different from above): 4.Ext: 5.PAG/CELL, <br /> 1. NAME: 2. AGENCY: 3. PHONE#: <br /> 2. SUBSTANCE TYPE: c.TYPE,: d.OTHER: <br /> 2,a.SUBSTANCE: b.QTY:>=< AmountMeaB+�re CHEMICAL <br /> 1. Anti Frct:ze = 4 Galls) <br /> 2 = <br /> 3. _ <br /> e.DESCRIPTION: Truck radiator hose burst causing release_ <br /> f-CONTAINED: g.WATER INVOLVED: h.WATERWAY: 1.DRINKING WATER IMPACTED <br /> o <br /> Yes No <br /> 3. a.INCIDENT LOCATION: Flying J- 1501 North Jacktone d.ZIP: <br /> b.CITY: c.COUNTY: 95366 <br /> Ripon San Joaquin County <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE:09/24/2007 b. TIME (Mi�Aary):1500 e.SITE: Other CLEANUP BY. <br /> d. INJURIES# 0 0 FATALS#: EVACS#: g• <br /> 0 0 Reporting Parry <br /> 0 <br /> Same as#7"PERSON NOTIFYING.OES'" <br /> <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: b•OTHER ON SCENE: c.OTHER NOTIFIED: <br /> Ia.ON SCENE: Fire Department <br /> d.ADMIN.AGENCY: San Joaquin County Emergency Services e-SEC.AGENCY: <br /> DOC-Unit' RWQCB Unit. SII <br /> f.NOTIFICATION LIST: <br /> p� —u pt35-D.O. IJ FOOD,&AG ....❑OSHA LJ USCO <br /> AAICUPA 1IC��J Usews l � I❑PAXI�&ASC ❑USDOI <br /> fQ DAGOSPR I__I AIR RSSOURCSS BD L]DOG IL�JI �1 <br /> DTSC f�JII CAI-TRANS I,,„��_11I 8B PARKS L��.11:OBS HAZhfAT[1fYIT ❑POC L.�OTHER <br /> RWQCM LJ CDP LJ SMSA LJ O-0S PLANS UNIT r❑SAM <br /> �('aJ US FFA ❑COASTAL COM ❑FEMA ❑OBS REO U vwms <br />