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DEPARTI LENT OF CALIFORNIA HIGHWAY PATROL HAZARDOUS MATERIALS CONFIRMED HAZARDOUS 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 CES CONTROL NUMBER A California Highway Patrol 66 (916) 327-3310 98-0242 NCIDENT DATE(MONTH,DAY,YEAR) TIME NOTIFIED TIME COMPLETii ED DATE COMPI�:cD(IF DIFFERENT) v� 01/18/98 2325 1630 01/19/98 C INCIDENT ADORESSILOCATION CITY/COMMUNITY COUNTY Z:P CODE Harnev Lane E/o De Vries Road Unincorporated San JoaQllin 95242 WEATHER(CHECK BEST DESCRIPTION) 1 Clear EST.TEMPERATURE ❑ ❑ 3 Rain ❑4 Snow D ❑ 5 Hail ❑ 6 Electrical storm ❑ 7 Fog ❑ 8 High wind ❑9 Other ❑40 Unknown PROPERTY USE(CODES ON REVERSE) SURROUNDING AREA(CODES ON REVERSE) PROPERTY MANAGEMENT ❑ Federal Cl State ❑ County ❑City ❑ Private ❑ Unknown RELEASE FACTORS(CHECK BEST CESCRIPTION(S)) TYPE OF EQUIPMENT INVOLVED MOBILE PROPERTY TYPE — 11 Intentional act — 70 Operational deficiency _ 10 Heating systems _ 10 Passenger vehicle/road — 12 Suspicious act 71 Collision/overtum _ 30 Air condition/refrig _ 20 Freight vehicle/road — 30 Failure to control hazmat _ 80 Natural condition _ 77 Chem processing _ 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 fuels stem _60 Heavy equip.indust./agri — 60 Design,construction 00 Undetermined — — — _ 98 No equipmentt involved _ 98 No mobile property installation deficiency _ 99 Other _ 99 Other 00 Undetermined 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 _ 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 Cther 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 Diesel Fuel 1993 3 PHYSICAL STATE STORED PHYSICAL STATE RELEASED QUANTRY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF RELEASE (LBS.,GAL,ETC.) 1 Air J 3 Ground (CODES ON REVERSE) —1 Solid �/ 2 Liquid —3 Gas —I Solid ✓ 2 Liquid _3 Gas 30 gal. 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 41 11 2 1250 gal. G CHEMICAL NAME OR TRADE NAME(PRINT OR TYPE) DOT ID NUMBER DOT HAZARD CLASS CASE NUMBER PHYSICAL STATE STORED PHYSICAL STATE RELEASED QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF RELEASE (LBS.,GAL.ETC.) 1 Air 3 Ground (CODES ON REVERSE) _1 Solid —2 Liquid—3 Gas _1 Solid _2 Liquid _3 Gas 2 Water — 9 Other CONTAINER DESCRIPTION CONTAINER TYPE I LEVEL OF CONTAINER(CODES ON CONTAINER MATERIAL CONTAINER CAPACITY _ 1 Fixed _ 1 Insulated (CODES ON REVERSE) REVERSE) (CODES ON REVERSE) (IBS.,GAL,ETC.) _ 2 Portable _ 2 Pressurized _ 3 Mobile _ 3 Armored MORE THAN TWO SUBSTANCES INVOLVED(LIST ADDITIONAL INFORMATION ON CHP 5M) H ❑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 8 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. 19 On-site fire services 58 Tox center 78 Shipping papers DECONI INJURIES FATALITIES — EXPOSED _ 25 Private info source _ 59 Chemtrec _ 87 Computer software 29 Off-site fire services 71 DOT manual 98 No reference Responding agency � — — — personnel _ 40 On-site non-fire services _ 73 MSDS material used _ 60 Off-site non-fire services _ 75 Placards/signs _ 99 Other Others — 54 Chemist VEHICLE MAKElYEAR VEHICLE LICENSE NO. STATE I VEHICLE LD.NO.(VIN) I CAIDOTIPUGICC NO. COMPANY NAME K REPORTING OFFICER NAMEJRANKII.D.NO.(PRINT OR TYPE) DATE COMMENTS ON REVERSE R. Wertman, Sgt. 8273 01/25/98 Yes ❑ No Destroy previous editions.