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CODES D. RROPERTY USE AND SURROUNDING AREA TYPE G EXTENT OF RELEASE 100 Public assembly 762 Hazmat chem mfg 950 Railroad 1 Confined to vehicle/equipment 200 Educational 767 Petroleum refinery 961 Freeway 2 Confined to room of origin Health care 800 Storage 962 County/City road 3 Confined to floor of origin Residential 931 Open land 963 Private road 4 Confined to structure of origin ovu Mercantile, Business 936 Vacant lot 965 Rest stop/vista point 6 Confined to property use of origin 600 Industrial, Utility 941 Open sea 966 ScaleAnspection facility 7 Release beyond property use of origin 650 Agricultural 942 Haroor/Port 099 Other(explain in 8 NO RELEASE 700 Manufacturing 946 Lake/Pond/River Comments) 9 Other(explain in Comments section) Q Undetermined G. CONTAINER TYPE LEVEL OF CONTAINER G.CONTAINER MATERIAL 11 Drum 24 Machinery or process equipment 11 Ground level 1 Iron and iron alloys 12 Cylinder 31 Sump/Pit 30 Above ground 2 Aluminum and aluminum alloys 13 Can or bottle 32 Pond or surface impoundment 40 Below ground 3 Copper and copper alloys 14 Carboy 33 Well 4 Plastic(includes fiberglass), rigid 15 Box or carton 41 Vehicular fuel tank 5 Plastic,flexible 16 Bag 98 NO CONTAINER 6 Wood,paper, and cellulose products 21 Tank or silo(including 99 Other(explain in Comments 7 Glass vehicle cargo tanks) Section) 9 Other(explain in Comments) 22 Pipe 00 Undetermined 0 Undetermined JUDICIAL DISTRICT BEAT NCIC NUMBER PLACARDS REQUIRED F OTOGRAPHS Lodi 902 9265 E Yes ❑ No Yes 0 No MILEPOST INFORMATION TIME O.E.S.NOTIFIED TIME CALTRANSICOUNTY ROADS NOTIFIED M ❑ Feet of milepost 2325 2325 ❑ At intersection wittl amev Lane 21 Or.500 Feet/elnie east of milepost De Vries Road CARRIER'S NAME PHONE NUMBER(INCLUDE AREA CODE) Union Pacific Railroad (916) 789-5241 N ADDRESS(INCLUDE CITY,STATE AND ZIP CODE) 9499 Atkinson Street Roseville, CA 95678 DRIVER'S NAME LICENSE NUMBER AND STATE PHONE NUMBER(INCLUDEAREA CODE) Conductor Boykin N/A ( (916) 789-5241 ADDRESS(INCLUDE CITY,STATEAND ZIP CODE) 9499 Atkinson Street Roseville, CA 95678 CHP NUMBER PUC NUMBER Enter at least one of CA T P either the CHP, DOT, ''' DOT NUMBER ICC NUMBER PUC, or ICC number. US � Mc � If applicable, enter cargo tank specification number and/or at least one of the following: CARGO TANK 0 SPECIFICATION NUMBER 1. CHP cargo tank registration number(CT .. DOT-E MC 2. DHS Waste Hauler Compliance Sticker number CITATION ISSUED OR COMPLAINT TO BE FILED OTHER HAZARDOUS MATERIALS VIOLATIONS(NON-CAUSATIVE) ❑ Yes ❑ No Not determined ❑ Yes 0 No PRIMARY CAUSE OF INCIDENT DID WEATHER CONTRIBUTE TO EITHER CAUSE AND/OR SEVERITY OF INCIDENT? ❑ Violation 34506(b)VC/C.C.R.Section ❑ Yes Q No R AFTER ACTION REPORT REQUIRED?(REFER TO G.O. 100.79) ❑ Other Code violation ❑ Yes ❑ No COLLISION REPORT MADE? NUMBER ❑ Other cause' ❑ Yes Q No DATE AND TIME SCENE DECLARED SAFE BY WHOM(NAME,TITLE AND AGENCY) S ROAD CLOSURE ❑ None ❑ Full—Hours 16.0 ❑ Partial—Hours: ❑ Alternative route—Hours16.0 Complete narrative on CHP 556 T ELEMENTS(AS APPLICABLE):(IF MORE THAN ONE CARRIER OR MORE THAN THREE COMMODITIES ARE INVOLVED,INCLUDE ADDITIONAL INFORMATION IN NARRATIVE.) 1. Sequence of events 3. Evacuation details 5. Cleanup actions 7. CHP personnel data—name, rank, I.D. no.,function, 2. Road closures 4. Environmental impact 6. Actions of other agencies exposure, hours PREPARERS NAME,RANK AND I.O.NUMBER DATEREVIEWER'S NAME,RANK AND I.D.NUMBER DATE R. Wertman. Sgt. 8273 01/25/98 �,� . PLsZ' �� q Z-3 :2L