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r OEPARThAENT OF CALIFORNIA HIGHWAY PATROL HAZARDOUS MATERIALS CONFIRMED HA,ZARDOUS MATERIALS INCIDENT REPORT CHP 407E(Rev 3-91)OPI 066 Refer to G.O. 100.79 ❑ Original ❑ Change ❑ Delete Yes ❑ No AGENCY NAME AGENCY I.D.NUMBER AGENCY INCIDENT NUMBER(HO.USE) AGENCY PHONE NUMBER I OES CONTROL NUMBER ,aiifomia Highway Patrol 66 (916) 327-3310 98-0242 NCIDENT DATE(MONTH,DAY,YEAR) TIME NOTIFIED TIME COMPLETED DATE COMPLETED(IF DIFFERENT) 01/18/98 2325 1630 01/19/98 _ INCIDENT ADDRESSILOCATION CRY/COMMUNITY COUNTY ZIP CODE C Harnev Lane E/O De Vries Road Unincoroorated San Joaauin 95242 WEATHER(CHECK BEST DESCRIPTION) U 1 Clear ❑ 3 Rain ❑4 Snow EST.TEMPERATURE D ❑ 5 Hail E] 6 Electrical storm [:] 7 Fog El High wind ❑ 9 Other ❑40 Unknown 40 PROPERTY USE(CODES ON REVERSE) SURROUNDING AREA(CODES ON REVERSE) PROPERTY MANAGEMENT 950 ❑ Federal ❑ State ❑ County ❑City Private ❑ Unknown RELEASE FACTORS(CHECK BEST OESCRIPTION(S)) TYPE OF EQUIPMENT INVOLVED MOBILE PROPERTY TYPE _ 11 Intentional act — 70 Operational deficiency _ 10 Heating systems _ 10 Passenger vehicle/road _ 12 Suspicious act J 71 CQllision/overtum _ 30 Air condition/refrig _ 20 Freight vehicle/road _ 30 Failure to control hazmat — 80 Natural condition _ 77 Chem processing J 30 Rail transport vehicle _ 31 Abandoned — 94 Fire/explosion _ 78 Waste recovery equipment _ 40 Water transport vessel E _ 40 Misuse of hazmat — 98 No release _ 96 Hazmat transfer equipment _ .50 Air transport vessel _ 50 Mechanical failure — 99 Other _ 97 Vehicle fuel system _ 60 Heavy equip.indust./agd _ 60 Design, construction — 00 Undetermined _ 98 No equipment involved _ 98 No mobile property installation deficiency J 99 Othermin cars _ 99 Other 00 Undetermined I— 00 Undetermined ACTION TAKEN(CHECK ONE OR MORE) — 42 ID/analysis of hazmat — 61 Crowd control — 92 Refer to proper authority _ 31 Rescue, remove from harm _ 43 Evacuation J 62 Traffic control — 97 Hazmat response,material _ 32 Extrication, _ 44 Establish safe area _ 63 Notify other agency determined to be non F 33 Emergency medical 45 Monitor 64 Provide public information hazardous — — — _ 35 Search _ 46 Decon-person/equip. _ 71 Investigate — 98 No action taken _ 36 Transport — 47 Decon-area(clean up) — 73 Shut down system — 99 Other 41 Remove hazard 48 Contain/control hazmat 82 Secure property CHEMICAL NAME OR TRADE NAME(PRINT OR TYPE) DOT ID NUMBER DOT HAZARD CLASS CASE NUMBER Phosphoric Acid 1805 I 3 PHYSICAL STATE STORED PHYSICAL STATE RELEASED QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF RELEASE (LBS.,GAL.ETC.) 1 Air J 3 Ground (CODES ON REVERSE) 1 Solid J 2 Liquid —3 Gas 1 Solid 2 Liquid _3 Gas 600 gal J 2 Water — 9 Other 7 CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER(CODES ON CONTAINER MATERIAL CONTAINER CAPACITY _ 1 Fixed _ 1 Insulated (CODES ON REVERSE) REVERSE) (CODES ON REVERSE) (LBS.,GAL,ETC.) _ 2 Portable _ 2 Pressurized 3 Mobile 3 Armored 21 11 1 14,500 gal G CHEMICAL NAME OR TRADE NAME(PRINT OR TYPE) DOT ID NUMBER DOT HAZARD CLASS CASE NUMBER Pmt 1263 3 PHYSICAL STATE STORED PHYSICAL STATE RELEASED QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF RELEASE (LBS.,GAL,ETD.) y Air J 3 Ground (CODES ON REVERSE) _1 Solid 2 Liquid—3 Gas _1 Solid 4 2 Liquid _3 Gas 500 a — 2 Water — 9 Other 7 CONTAINER DESCRIPTION CONTAINER TYPELEVEL OF CONTAINER(CODES ON CONTAINER MATERIAL CONTAINER CAPACITY _ 1 Fixed _ 1 Insulated (CODES ON REVERSE) REVERSE) (CODES ON REVERSE) (LBS.,GAL,ETC.) _ 2 Portable _ 2 Pressurized J 3 Mobile _ 3 Armored 13 1 11 2 1 gad MORE THAN TWO SUBSTANCES INVOLVED(LIST ADDITIONAL INFORMATION ON CHP 556) H E Yes ❑ No SPECIAL STUDIES-LOCAL USE SPECIAL STUDIES STATE USE 1. A B C D 2, A B C D 3. A B C D 4. A B C D 5. A B C D 6. A B C D HAZMAT IDENTIFICATION SOURCES(CHECK BEST DESCRIPTION(S)) HAZMAT CASUALTIES NO.OF NO.OF NO. J 19 On-site fire services 58 Tox center J 78 Shipping papers DECONJ INJURIES FATALITIES EXPOSED J 25 Private info source 59 Chemtrec _ 87 Computer software — Responding agency — 29 Off-site fire services J 71 DOT manual — 98 No reference personnel 0 0 0 _ 40 On-site non-fire services _ 73 MSDS material used 60 Off-site non-fire services _ 75 Placards/signs _ 99 Other Others 0 0 0 54 Chemist VEHICLE MAKENEAR VEHICLE LICENSE NO. STATE VEHICLE I.D.NO.(VIN) CAIDOTIPUCIICC NO. COMPANY NAME K Locomotive Entine none IAPOABI6 none Union Pacific Railroad REPORTING OFFICER NAME/RANKII.D.NO.(PRINT OR TYPE) DATE COMMENTS ON REVERSE L R. Wertman, Sgt. 8273 01/25/98 Yes ❑ No Destroy previous editions.