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_'FrQm:Cal EMA (State Warning Center) 9168458910 11117/2010 10:51 #381 P.0011002 <br /> l <br /> California Emergency Management Agency d <br /> Hazardous Materials Spill Report <br /> DATE: 11/17/2010 RECEIVED BY: CONTROL#: <br /> TIME: 1013 Cal EMA- Ronald Demayo Cal EMA- 10-6901 w� <br /> OSPR NRC r :+ <br /> La. PERSON NOTIFYING Cal EMA: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4. Ext: S.PAGICELL: <br /> John fallen J.R. Simplot 208-389-7219_ Bv1'60,,jP U i <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:>=< Amount Measure c.TYPE: d.OTHER: <br /> i <br /> 1.Liquid Fertilizer = 200 Gal(s) OTHER Liquid <br /> (LI N32) Fertiliser <br /> 2. <br /> 3. = i <br /> t. DESCRITITI€3N: Caller states a driver was transferring liquid fertiliser from a storage tank to his truck when <br /> the camlock cap came off resulting in the release of substance. The pump was shut off and all <br /> of the substance was contained to the facility. An outside contractor will be called for clean <br /> tip <br /> f.CONTAINED: g.WATER h.WATERWAY: i.DRINItMG WATER IINIPACTID <br /> INVOLVED: <br /> Yes No <br /> j.KNOWN]IMPACT None <br /> 3. a.INCIDENT LOCATION: 4853 East Carpenter Road, Simplot{Tro-wer Solutions <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Stockton San Joaquin County 95215 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (military).. C.SITE: d. CAUSE <br /> 11117/2010 0930 MerchanbSusinesS Fluman Error <br /> e. IN.MIRIES is FATA111'1'Y g. EVACUATION la.C L:I-,AA"+t*PIRY3 <br /> Contactor <br /> ............................ ...............................- <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> T.R. Simplot 209-327-6441 <br /> e.MAIL ADDRESS: f.CITY: g.STATE: h.ZIP: <br /> 4863 East Carpenter Road,Simplot Grower Stockton CA 95215 <br /> Solutions <br /> 6, NOTIFICATION INFORMATION: <br /> �a.ON SCENE: b.OTIIER ON SCENE: c.OTHER NOTIFIED: <br /> San Joaquin County OES,San <br /> Rnuluin County MPA <br /> d.ADMIN.AGENCY: San Joaquin County e.SEC.AGENCY: <br /> rntergcncy Services <br /> L ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RWQCB Unit: SA <br /> ®AA/CUPA ®USFWS ❑CDPH-D.O. ❑FEMA ❑Cal EMA REG ❑USi ots ❑OTHER <br /> ®DFG-OSPR ❑AIR RESOURCES BD ❑DOG ❑FOOD&AO ❑OSHA ❑USCG <br /> ®DTSC ❑CALTRANS ❑DPR ❑LANDS ❑PARKS&REC ❑co/WP <br /> N RWQCB ❑CDF ❑EB PARKS ❑Cal EMAHAZMATUb=❑PUC ❑C.Mlth <br /> CR US EPA 11 COASTAL COM ❑EMSA ❑Cal EMA PLANS UNIT ❑SF.M ❑Co/E-filth <br />