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10-08-2006 18:40 From-OES HQ SACRAMENTO W/C 916-845-8910 T-363 P.001/001 F-690 <br /> 01;1S <br /> ;� GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> Hazardous Materials Spill Report <br /> nc) <br /> DATE: 10/08/2006 RECEIVED BY: CONTROL#: <br /> CIMS: 1823 0E• Bob Mcrae OES- 06-5987 <br /> OSPR- NRC- <br /> La. PERSON NOTIFYING GOVERNOR'S OES: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5. PAG/CELL: <br /> ` Bob Newman Stockton Fire Dept. 209-639.2241 <br /> l.b. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2, AGENCY: 3. PRONE#: 4.Ext: 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:i=< Rmouar Measure C.TYPE: d.OTIILR: <br /> 1.Ammonia = UNK Unknown CHEMICAL, <br /> VAPOR <br /> 2. _ <br /> 3. _ <br /> c.DESCRIP'T'ION: The ammonia leaked from an unknown source in the compressor room. The aninionia tame <br /> has bczn shut clown and they are looking for the source of the leak. <br /> E CONTAINED: g.WATER INVOLVED: h.WATERWAY: L DRINKING WATER IMPACTED <br /> Yes No No <br /> 3. a.INCIDENT LOCATION: 1111 Navy Dr. <br /> b.CITY_ c. COUNTY: d.ZIP: <br /> Stockton San Joaquin County <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: 10/05/2006 b. TIME (Mitirary). 1650 C.SITE: Merchant/Business <br /> d. INJURIES# e.FATALS#: f.EVACS#: g.CLEANUP BY: <br /> 0 0 0 Unknown <br /> Same as#1."PERSON NonrymG on,, <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> Zachy Farms <br /> e.MATT.ADDRESS: f.CITY: g.STATE: h.ZIP: <br /> 1 i l 1 Navy Dr. Stockton CA <br /> b. NOTIFICATION INFORMATION: <br /> k.ON SCENE: b.OTHER ON SCENE: G OTHER NOTIFIED; <br /> Fire Dept. Co.Health,Co-OES <br /> d.ADMIN.AGENCY: Sari Joaquin County Emergency Scrviccs e.SEC.AGENCY: <br /> T.NOTIFICATION LIST: DOC Unit: RWQCti Unit: 5D <br /> C�2 AA'CUPA V'J u,FwS I DHS-u.o. ISI FOOD 3,AG _I OSHA F I USCG <br /> L�` DFG-0SPR I� AIR RESOURCES HDI I POO ❑LANDS ❑_ PARKS&PIC Imo�.�USM�c✓`�D'r'sC yamy�_I CALTRANS I I EB PARKS ❑p Ott%HAZMATUNIT I PUC Ej OTHER <br /> ^^�RWWB L..1 COF I I SMSA L�OES PLANS UNIT El SFM <br /> I. UJ�♦'A I-. I COASTAL COM I FEMA ❑OtS RF.G I�lf5MMs <br />