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Oi-17-2006 21:47 From-OES HQ SACRAMENTO W/C 916-845-9910 T-769 P.001/001 F-011 <br /> 011f, ,.S <br /> GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> Hazardous Materials Spill Report <br /> DATE: 07/17/2006 RECEIVED BY: CONTROL#: <br /> TIME; 2129 OES- Kavin Godwin OES- 06-4208 <br /> OSPR- NRC- 804486 ,n�:) <br /> La. PERSON NOTIFYING GOVERNOR'S OES; <br /> 1. NAME: 2. AGENCY: 3. PHONE#; 4.Ext: S.PAG/CELL: <br /> xxx NRC 800-424-8802 <br /> l.b. PERSON REPORTING SPILL(If different from above): o <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/CELL: dp <br /> Shawn Mendoza St services 209-943-5662 r <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY;>=< Anwunr Heusure C.TYPE: d.OTHER: <br /> 1,Diesel = 100 Gal(s) PETROLEUM <br /> 2, <br /> 3. <br /> e.DESCRIPTION; Per NRC Fax,Caller stated there was a release of materials frorn a tanker truck due to an <br /> operator over Mling the tank.Clean-u is underway and a contractor has been hired. <br /> f.CONTAINED; g.WATER INVOLVED: h.WATERWAY: L DRINKING WATER IldPACTED <br /> Yes No <br /> 3. a.INCIDENT LOCATION: 2941 Navy Dr <br /> b.CITY: c.COUNTY: d.ZIP; <br /> Stockton San Joaquin County 95206 <br /> 4.INCIDENT DESCRIPTION; <br /> a.DATE; 07/I7/2006 b. TIME (44ilitary):2000 G SITE: MerchanvBusiness <br /> d. INJURIES# e.FATALS#: L EVACS#; g.CLEANUP BY: <br /> 0 0 0 Contractor <br /> Same as#1"PERSON NOTIFYING OES" <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: e.PRONEM d.EXT.: <br /> Shawn Mendoza St Services 209-943-5662 <br /> e.MAIL ADDRESS: f.CITY: g.STATE: h.ZIP: <br /> 2941 Navy Dr Stockton CA 95206 <br /> 6. NOTIFICATION INFORMATION: <br /> �.ON SCENE: b.OTHER ON SCENE: c.OTHER NOT1UD: <br /> d.ADMIN.AGENCY; San Joaquin County Emergency Services e.SEC.AGENCY: <br /> f.NOTIFICATION ILII��ST: DOG Unit•. RWQCa Unit: 513 <br /> nW AICUPA Vel asFws 1 DEiS.D.O- �I-1 FOOD A AO EJ OSHA �.. f__I usCC <br /> ICS DFG-OSPR LJ AIR MSOURCES&D I_..I DOG LJ Lnims ❑PARKS -,PC ❑USDOJ <br /> M1 a'rse I-JCAFTs ws f�EB I.."s ❑Ori HALMATUMT U PUC ❑OTHRK <br /> N RWQCH LJ I CDF Ll>:MSA 1:1 OES PL A.Ns LNrr ❑sw <br /> P us EPA Ii .I. COASTAL COM I I FPMA ❑OP.S Rfsa U usmms <br />