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11-20-2006 1"" Vie-From-OES HQ SACRAMENTO W/C 916-845-8910 T-409 P.001/001 F-334 <br /> ,A=r.��' GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> Hazardous Materials Spill Report <br /> *a...1Ain.r-tiv.hr <br /> RECEIVED BY: CONTROL#: <br /> DAZE: 11/2012006 OES_ Bob Mcrae OES- 06-6891 <br /> TIM1E: <br /> 1054OSPR- NRC- <br /> 1.2. PF-RSON NOTIFYING GOVERNOR'S OES: 3. PHONE#: 4.Ext*_ 5.PAG/CELL- <br /> 1, NAIVY 2. AGENCY: <br /> Jaine Perez San Joaquin County Public 209-468-3066 <br /> Works <br /> 1.b. PERSON REPORTING SPILL(If different from above): 4.Ext: 5.PAG10ELL- <br /> 1. NAME: 2. AGENCY: 3. PHONE#: <br /> 2. SUBSTANCE TYPE: Measure r.'TYPE: d.OTt1PR: <br /> b. TY-.—< Arsouf�l <br /> 2.a.SU�SUBSTANCE: Q 200 Gal(s) PETROLEUM <br /> 1,Diesel <br /> 2. <br /> 3. <br /> e.DESCRIPTION. An emPloyee was fueling;a truck and overfilled tank <br /> f.CONTAINED: g-WATER INVOLVED lt.WATERWAY= NDRINKING WATER IMPACTED <br /> Yes No <br /> 3. a.INCIDENT LOCATION: 1 e7 CCE.HATney Ln. d.ZIP; <br /> b.CITY <br /> Lodi San Joaquin County <br /> 4.INCIDENT DESCRIPTION: <br /> a.DAT'E:11/19!2006 b. TIME 041114910'0930 C.SITE: Other �.CLEANUP BY: <br /> d. INJURIES# e.1~ATALS#: f.EVACS#: Repot Parry <br /> 0 0 0 <br /> same as#;l."pPRSON N,OT.IFYING OF!.§ <br /> S. SUSPECTED RESPONSIBLE PAK'IY: c.PHONEM d.EXT.: <br /> a.NAME: bl. AGENCY: <br /> f.CITY: g.STATE: h.ZIP: <br /> e,MAIL ADDRESS: CA <br /> 6, NOTIFICATION INFORMATION: b.OTHER ON SCENE: c.OTHER NOTIk�D- <br /> �a.ON SCENE: Co.OES,Co,Health <br /> d.ADMIN.AGENCY: San,ids[quin COUnLY EMMCUCY SorvieeS e.SEC.AGENCY: <br /> DOG(Snit: RWQC13 U11h; 5Ti <br /> f.NOTIFICATION LIST: <br /> pp,�I�S�I- / ❑Dila-D O, �—_i FOOD&AO r❑^�OSIiA Lrs VCO <br /> fLJ 1wCUPA r�r J USFWS u LANDS L,!PAf &K2C Is_J�USW[ <br /> u DFGDSPR J Alr tesoURCM BP`ri r} u onim <br /> V`J Dl'SC I❑CALY[dA19S Ir•��9D PARKS ❑QEa[[AZMATUNI"S' I J YUC <br /> L J Kwocs L CAF LJ Y1MSA ❑0E9 P[.P.1V5lILVCI' C]U M —. <br /> h�771I ❑FEMA C�ops Rw ❑USM MS <br /> �(J'is EPA CI�oASTAl-COM <br />