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STATE OF C ALIFQRNIA, DEPARTMENT OF CALIFORNIA HIGHWAY PATROL HAZARDOUS MATERIALS INCIDENT REPORT DES CONTROL NUMBER COLLISION REPORT CHP 407E(Rev.3-15)OPI 062 Refer to HPM 84.2,Chapter 2 18-1161 ❑Yes NUMBER N No HAZMAT CASUALTIES NO.EXPOSED/ NO. NO. CITY JUDICIAL DISTRICT PHOTOGRAPHS BY N NONE DECONNED INJURED KILLED Unincorporated Stockton AGENCY PERSONNEL 0 0 COUNTY NCIC HAZMAT PLACARDS DISPLAYED OTHERS 0 0 0 San Joaquin 9266 N Yes ❑No INCIDENT DATE(MM/DD/YYM INCIDENT TIME TIME CALTRANS/COUNTY ROADS NOTIFIED TIME O.E.S.NOTIFIED STATE HIGHWAY RELATED 02/21/2018 0415 HOURS 0500 HOURS 0800 HOURS ❑Yes ®NO INCIDENT OCCURRED ON ❑AT INTERSECTION WITH Bryon Road N OR North of Mountain House Parkway MILEPOST INFORMATION GPS COORDINATES LATITUDE LONGITUDE NAME(FIRST,MIDDLE,LAST) DRNER'S LICENSE NUMBER STATE VEH.YEAR MAKE LICENSE NUMBER STATE Jose Abuindio Alfarohuitron A8255229 ICA 2015 Freightliner 9FO2771 CA STREETADDRESS VEH.YEAR MAKE LICENSE NUMBER STATE 2118 Canoes Gardens Avenue, 181 1999 Utility Trailer 4FF9202 CA CITYISTATE0P CODE VEH.YEAR MAKE LICENSE NUMBER STATE San Jose,CA 95125 HOME PHONE BUSINESS PHONE CARRIER NAME (408)518-9188 HASA INC. HAZMAT IDENTIFICATION SOURCES(CHECK ALL THAT APPLY) REGISTERED OWNER ❑SAME AS DRIVER N On-site fire services ❑Chemtrec Rory Manley N Private info source ❑Poison Control Center OWNER'S ADDRESS ❑SAME AS DRIVER ❑Off-site fire services ❑Safety Data Sheet 23119 Drayton Street, Saugus,CA 91350 ❑On-Site non-fire services ❑Placards/Signs VEHICLE IDENTIFICATION NUMBER ❑Off-site non-fire services ❑Shipping papers ❑Computer software N Emergency Response Guidebook 3AKJGEDV9FDGL5412 ❑Chemist ❑No reference material used VEHICLE TYPE CA NUMBER DOTNUMBER ❑Other 75 28 171496 CHEMICALTTRADE NAME UN DOTHAZARD QUANTITY RELEASED EXTENT OF RELEASE PHYSICAL PHYSICAL STATE NUMBER CLASS (LBS.,GAL.,ETC) STATE STORED RELEASED Hvuo Chlorite Solution 1791 8 180 pounds Outside vehicle Liquid Liquid CONTAINER TYPE CONTAINER CAPACITY(LBS.,GAL.,ETC.) CONTAINER MATERIAL LEVEL OF CONTAINER Cargo tank 50,000 pounds Aluminum/Aluminum alloys Above ground CHEMICALrTRADE NAME UN DOT HAZARD QUANTITY RELEASED EXTENT OF RELEASE PHYSICAL PHYSICAL STATE NUMBER CLASS (LBS.,GAL,ETC.) STATE STORED RELEASED CONTAINER TYPE CONTAINER CAPACITY(LBS.,GAL,ETC.) CONTAINER MATERIAL LEVEL OF CONTAINER PROPERTY USE SURROUNDING AREA PROPERTY MANAGEMENT County/City road Open land County RELEASE FACTORS EQUIPMENT TYPE INVOLVED HAZMAT CONFIRMED Failure to control hazmat Hazmat transfer equipment ®Yes ❑No CITATION ISSUED OR COMPLAINT TO BE FILED PRIMARY CAUSE OF INCIDENT OTHER HAZARDOUS MATERIALS VIOLATIONS(NON-CAUSATIVE) ❑Yes ❑No N Not determined N Violation 23114 VC ❑Yes N No ❑Other Code violation DID WEATHER CONTRIBUTE TO CAUSE OR SEVERITY OF INCIDENT? ❑Other cause ❑Yes N No WEATHER ELEMENTS(OUTLINE THE FOLLOWING DNA CHP 556.INCLUDE ADDITIONAL INFORMATION AS NECESSARY) N Sequence of events N Evacuation details N Cleanup actions N CHP On-scene Personnel(name,rank, ID N Road closures N Environmental impact N Actions of other agencies number,function,exposure,hours) COMPLETE THE FOLLOWING N Incident Action Plan N Site Safely Plan N Proposition 65 Letters:County Health/County Board of Supervisors DATE AND TIME SCENE DECLARED SAFE BY WHOM(NAME,TITLE AND AGENCY) 02/21/2018 1000 Houas Garrett Backus,San Joaquin County Environmental Health Department PREPARER'S NAME,RANK,AND ID NUMBER DATE 7REVIAME,RANK,AND 10 NUMBER DATE Sergeant Lecce, I5236 02/22/2018 Wharry, 14792 02/22/2018 Destroy Previous Editions An Internationally Accredited Agency Chp4O7E 0515.pdI