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07-14-2004 16:13 From-OES HQ V^'4MENTO W/C 916-845-8910 T-385 P.001/001 F-720 <br /> 1,4 GOVERNOR'S OFFICE;OF ERGENCY SERVICES R. <br /> Hazardous Materials Spill Report <br /> 711wgN•7-Wvwid. <br /> DATE: 07/14/2004 RECEIVED BY: CONTROL#: <br /> TIME: 1551 OES- Danelle Langford OES- 04-3652 <br /> OSPR- NRC- <br /> l.a. PERSON NOTIFYING GOVERNOR'S OES: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/CELL,: <br /> J Flying J <br /> d 1.b. PERSON REPORTING SPILT.(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:>=< Amount Measure c.TYPE: d.OTHER: <br /> 1.Diesel Fuel = 2-3 Gal(s) PETROLEUM <br /> 2. _ <br /> 3. <br /> e.DESCRIPTION: Customer on premises had a broken fuel line. Tnfo on responsible party,CO/502DGP, <br /> TK#1221,Co.Name CNC Trucking,out of Las Vegas,Nv- <br /> f.CONTAINED; g.WATER INVOLVED: h.WATERWAY: i.DRIMNG'WATER IMPACTED <br /> Yes No <br /> 3. a.INCIDENT LOCATION: 1501 N.Jacktone Rd. <br /> b.CITY: c.COUN'T'Y: d,ZIP: <br /> Ripon San Joaquin County 95366 <br /> 4. INCIDENT DESCRIPTION: <br /> a.DATE.-07/14/2004 b. TIME (MiRwy); 15.45 c.SITE: Service Station <br /> d. INJURIES# e. FATALS#: f.EVACS#: g.CLEANUP BY: <br /> 0 0 0 Reporting Party <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 Emergency Services e.SLC.AGENCY: <br /> f.NOTTMICATION LIST: DOG Unit: r I RWQCB Unit; 5B <br /> Q AA/CUFA D USFWS L�DHS-D O. fL FOOD&AG U OSHA USCG <br /> DFO.OSPR ❑AIR RESOURCES BD In.,J DOG I LANDS P-MS't RBC El S001 <br /> pCD DISC 0 CALTRANS L EE PARKS L OES HAZMATUKT nU PUC <br /> ( ❑OTAER <br /> L'J RWQCD ❑CDF I.1 nMSA IF-1 0ES PLANS UNIT I SFM <br /> D UL-1 <br /> S RPA COASTA)_COM �_J FEMA oEs REG ❑USMMS <br />