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From:Cal EIA (State Warning Center) 9168458910 02/22/2010 11 :31 #992 P.0011001 <br /> California Emergency Management Age a <br /> Hazardous Materials Spill Rep <br /> DATE: 02/22/2010 RECENED BY: CONTROL#: <br /> TIME: 1115 Cal EMA- Ronald Demayo Cal EMM. 10-1325 r O <br /> OSPR- NRC- <br /> 1.a. PERSON NOTIFYING Cal EMA: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CELL: <br /> Jason Patriquin Veeder Root Compliance 335-315-2816 6i <br /> Lb. PERSON REPORTING SPILL(If different from above): i <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:>=c Amount measure c.TYPE: d.OTHER: ' <br /> 1.Antifreeze - 2 Gal(5) CHEMICAL <br /> 2. - <br /> 3. _ <br /> e.DESC1-II1<''#TON: Caller states a vehicle pulled onto the site and leaked substance onto pavement only. The site <br /> cleaned up substance using absorbent pads. <br /> f.CONTAINED: g.WATER h.WATERWAY: i.DRI1VKING VYATER IMPACTED <br /> INVOLVED: <br /> Yes No <br /> j.KNOWN IMPACT line <br /> 3. a.INCIDENT LOCATION: 2508 Country Club.Blvd,Safeway Store 1769 <br /> b.CITY: e. COUNTY: d.ZIP: <br /> Stockton San Joaquin County 95204 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (A&Atary). C.SITE: d. CAUSE <br /> 02/22/2010 1100 IvIerchant/Business Other <br /> Description for Other: Customer <br /> vehicle/mechanical. <br /> C .iNJ[ll IES i C�� i.f cl.I[ E. f 4Tf�if.C1r�J Fol I 1 .�-.1� ..f 1>.13 BY- <br /> . <br /> -------- ---- ---- <br /> ...--_..... On-site employee. <br /> w........K....»... -..w .__....»------ <br /> S. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> Unknown Customer <br /> e.MAIL ADDRESS: f.CITY: g.STATE: h.ZIP: <br /> CA <br /> 6. NOTIFICATION INFORMATION: <br /> a.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIM: <br /> d.ADMIN.AGENCY: sant Joaquin county e.SEC.AGENCY: <br /> kmergency services <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RWQCB Unit: 5B <br /> ®AAICUPA ®Daws ❑CDPH-D.O. ❑FEMA ❑Cal EMA REO ❑Usillms ❑OTHER <br /> ®DFO.OSPR ❑ATR RESOURCES BD ❑DOU ❑FOOD&AO ❑OSHA ❑USCG <br /> O DTSC ❑CALTRANS ❑APR ❑LANDS ❑PARKS&REC ❑CawP <br /> ®RWQCB ❑CDF ❑EB PARKS ❑Cal EMAHAMfATUMT❑PUC ❑CGIFIlth <br /> ®US EPA ❑COASTAL COM ❑EMSA ❑Cal EMAPI.ANS UICT ❑SFM ❑C"E-Hlth <br /> Vi:arning..ertter`et�es.ca.gov:R3_R RC'j-FAIA. XM, ,rsC.f:R.Agneall..om <br />