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06-Q9-2008 09:34 From-OES HQ SA�khtI�Qt, r—__"1 916-845-8910 T-773 P.001/001 F-990 <br /> 0 ,1'= � � GOVERNOR'S G. .CE OF EMERGENCY <br /> D SERVICES <br /> FWHazardous Materials Spill Report <br /> EDA2.-. 06/09/2008 RECEIVED BY: CONTROL#: <br /> 0920 OES- Courtland Ellis OES• 08-4099 <br /> OSPR- NRC- <br /> 1.a. PERSON NOTIFYING GOVERNOR'S OES: <br /> 2. AGENCY: 3. PHONE#: 4.Ext: S.FAGlCELL: <br /> 1. NAME: <br /> O" Denny Bryant Carpenter Co 209-982-4800 <br /> 1.b. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAC/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUi3STANCE: b.QTY:—< A/nou"' Measure C.TYPE: d.OTHER: <br /> 1. GP6515-Polyol 10 Gal(s) CHEMICAL <br /> z. <br /> 3. <br /> e.DESCRIPTION: Driver connection error caused this release <br /> f.CONTAINED. g,WATER INVOLVED: h.WATERWAY: i.DRINKING WATER IMPACTED <br /> Yes No No <br /> 3. a. INCIDENT LOCATION: 17100 South Harlan Rd <br /> ZIP- <br /> b. CITY: c.COUNTY: d.ZIP: <br /> Lathrop San Joaquin County 95330 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: 06/09/2008 b. TIME (Military).0910 G SITE: MerchanUB.CLEANUP BY: <br /> s <br /> d. INJURIES# e.FATALS#: E EVACS#: R.CLEANUP <br /> Pany <br /> 0 0 0 <br /> Same as#!1."PERSON NOTIFYING OES" <br /> 5. SUSPECTED RE,SPONSTSLE PARTY: <br /> a.NAME: b. AGENCY: c.pFIONE#: d.EXT.: <br /> Carpenter Co 209-982-4800 <br /> e.MAIL ADDRESS: f CITY: g.STATE: h, M: <br /> 17100 South)'-Harlan Rd Lathrop CA 95330 <br /> 6. NOTIFICATION INFORMATION: <br /> i�a.ON SCENE: b.OTHER ON SCENE: c. OTHER NOTIFIED- <br /> s. FD,San Joaquin Co OE <br /> d.ADMIN.AGENCY: San Joaquin County emergency Services e.SEC.AGENCY: <br /> f.NOT MCATION LAST, DOG Unit: RWQCB Unit: 5S <br /> L71 AA,CUPA L_I UiPWS L7 OHS-D.O, -I FOOD tr AG OSHA USCG <br /> DKi-OSPR Cl AIR RESOURCES PP I. I DOG L NDS PAKKS&REC L PUC U�OUSAOI <br /> G9 D•I•SC IL��J11 C.ALTRANS .I 58 PARKS I_I UB+IIAZMAI'uN1T u THCR <br /> IGJ KWQCB I— CDF L[EWA I�OP-S PLANS UNIT IJ SFM <br /> h 1 US EPA k COASTAL CUM IJ PAMA 7;OES REG �USMMS <br />