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From:Cal EMA (State darning Cuter) 9168458910 06/2.2112010 10:01 #369 P.001/002 <br /> California Emergency Management Age <br /> Hazardous Materials Spill Rap 4 <br /> DATE: 06/22/2010 RECEIVED BY: CONTROL#: <br /> TIME: 0936 Cal EMA- Ronald Uemayo Cal EMA- 10-3785 O <br /> OSPR - NRC- <br /> La. PERSON NOTIFYING Cal EMA: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CE <br /> Roger Hoffdahl Coni Product.; 209-982-1920 233 <br /> I.b. PERSON REPORTING SPILL(If different from above): Y i <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CELL: .i <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:>=a Amount Measure c.TYPE; d.OTHER: <br /> 1. NALCO 3DT 289 S Galls} CHEMIC-AL <br /> (Cooling Tower Water <br /> Treatment) <br /> 2. _ <br /> 3. _ <br /> C..1 ESC R(PTION. Caller states a delivery driver was set up to pump into their tank and when he turned the <br /> pwnp system.on,the hose cupling came loose resulting in the release of substance to asphalt. <br /> The system was immediately shut down and clean up is in progress using sodaash and <br /> shovels. <br /> f. CONTAINED: g.WATER h.WATERWAY: i.DRE*4E vG WATER INIPACTED <br /> INVOLVED: <br /> Yes No <br /> j. KNOWN EAPACT None <br /> 3. a.INCIDENT LOCATION: 1021 Industrial Drive,Corsa Products Stockton Plant <br /> b. CITY: c.COUNTY: d.ZIP: <br /> Stockton San Joaquin County 95206 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (Military): C.SITE: d. CAUSE <br /> 06/22.i2010 0905 [ndustrial'Plant. `�lechan.ical <br /> �. INSURIES f. FATALITY g.:EVAC1 ?afION It.CLE''iiNt"I"By. <br /> Responsible Party <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> NAi,CO Unknown <br /> e.MAIL ADDRESS: f.CITY: g. STATE: h.ZIP: <br /> 1601 West:Diehl Road Naperville it. 60563 <br /> 6. NOTIFICATION INFORMATION: <br /> Ia.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> Other `pan Joaquin County Health Dept Stockton City Fire Dept and San <br /> Joaquin County OES <br /> d.ADMIN.AGENCY: San Joaquin County e.SEC.AGENCY: <br /> Emergency Sen ices <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RWQCB Unit: 5B <br /> N AA/CUPA N USFWS ❑CDPH-D.O. ❑FEMA ❑Ca!EMAREG ❑USMMS ❑O'i"FC R <br /> N DFG-OSPR ❑AIR RESOURCES BD ❑DOG ❑FOOD&AG ❑OSHA ❑USCG <br /> N DTSC ❑CALTRAN'S ❑DPR ❑LAHDS ❑PARKS&REC ❑CO/WP <br /> N RWQCB ❑CDF ❑EB PARKS ❑Cal EMAHAZMATU=❑PUC ❑Co'wth <br /> ®US EPA 11 COASTAL COM ❑EMSA 0 Cal BMAPLAus= ❑SFM ❑CafE-Hlth <br />