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DEPARTMENT OF CALIFORNIA HIGHWAY PATROL HAZARDOUS MATERIALS CONFIRMED HAZARDOUS MATERIALS"INCIDENT REPORT CHP 407E Rev 3-9T OPI 066 Refer,to G.O. 100.79 ❑ Original ❑ Change ❑ Delete ❑ Yes ❑ No AGENCY NAME rAGEFN�.NUMBER]AGENCY INCIDENT NUMBER(HO.USE) AGENCY PHONE NUMBER DES CONTROL NUMBER Califomia Highway Patrol {918)327-3310 INCIDENT DATE(MONTH,DAY,YEAR) TIME NOTIFIED 009893 B TIME COMPLETED DATE COMPLETED(IF DIFFERENT) 09/06/95 0600 1300 09/08/95 C 1HCIDENTADORESSROCATION CnYlCOMMUNnY COUNTY ZIP CODE C � Mariposa Rd. .5 miles E. of MurDhv Rd. Unincomorated San Joaquin 95208 ' WEATHER(CHECK BESTDESCRIP77ON) © 1 Clear ❑3 Rain ❑4 Snow EST.TEMPERATURE ❑5 Nail ❑6 Electrical storm ❑7 Fog ❑8 High wind ❑9 Other 0'40 Unknown 65 PROPERTY USE(CODES ON REVERSE) SURROUNDING AREA(CODES ON REVERSE) PROPERTY MANAGEMENT 650650 11 Federal ❑State ❑ County El City El private ❑Unknown RELEASE FACTORS(CHECK BEST DESCRIPM-I(S)) TYPE OF EQUIPMENT INVOLVED MOBILE PROPERTY TYPE 11 Intentional act 70 Operational deficiency _ 10 Heating systems 10 Passenger vehiGelroad l — 12 Suspicious act 71 Collision/overtum _ 30 AIr condition/refrig J 20 Freight vehiGelroad 30 Failure to control hazmat - 80 Natural condition _ 77 Chem processing 30 Rall transport vehicle 31 Abandoned 94 Fire/explosion 78 Waste recovery equipment E 40 Water transport vessel _ 40 Misuse of hazmat 98 No release — 96 Hazmat transfer equipment 50 Air transport vessel _ 50 Mechanical failure — 99 Other ___.. 97 Vehicle fuel system 60 Heavy equip.industdagri 60 Design,construction w 00 Undetermined — 98,No equipment involved — 98 No mobile property installation deficiency J 99 Other azo tanks _ 99 Other ; _ 00 Undetermined 00 Undetermined ACTION TAKEN(CHECK ONE OR MORE) 42 ID/analysis of hazmat J 61 Crowd control _ 92 Refer to proper authority _ 31 Rescue,remove from harm _ 43 Evacuation J 62 Traffic control 97 Hazmat response,material ; J 32 Extrication, J 44 Establish safe area J 63 Notify other agency determined to be non F J 33 Emergency medical J 45 Monitor J 64 Provide public information hazardous 35 Search _ 46 Devon-persan/equip. J 71 Investigate _ 98 No action taken — 36 Transport J 47 Decon-area(clean up) _ 73 Shut down system _ 99 Other J 41 Remove hazard J 48 Contain/control hazmat _ 82 Secure property. CHEMICAL NAME OR TRADE NAME(PRINT OR TYPE) DOT ID NUMBER DOT HAZARD CLASS CASE NUMBER Gasoline UN1203 3 PHYSICAL STATE STORED PHYSICAL STATE RELEASED QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF RELEASE (LBS.GAL.ETC J 1 Ali J 3Ground ICODESONRFYERSE] 1 Solid 4 2 Liquid_3 Gas 1 Solid 4 2 Liquid _3 Gas 8,290 Gal _ 2 Water 9 Other 7 CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER(CODES ON CONTAINER MATERIAL CONTAINER CAPACITY 1 Fixed 1 Insulated (CODES ON REVERSE) REVERSE) (CODES ON REVERSE) (LBS,GAL,ETC.) 2 Portable 2 Pressurized _7 3 Mobile _ 3 Armored 21 30 2 4,900 Gal. G CHEMICAL NAME OR TRADE NAME(PRINT OR TYPE) DOT ID NUMBER DOT HAZARD CLASS ICASENUMBER PHYSICAL STATE STORED PHYSICAL STATE RELEASED QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF RELEASE (LBS.,GAL.ETC.) _ T Air 3 Ground (CODES ONREVERSE) _1 Solid _2 Liquid=3 Gas —I Solid _2 Liquid —3 Gas _ 2 Water _ 9 Other CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER(CODES ON CONTAINER MATERIAL CONTAINER CAPACITY _ 1 Fixed _ 1 Insulated (CODES ONREVERSE) REVERSE) (CODES ON REVERSE) (LBS..GAL,ETC.) 2 Portable _ 2 Pressurized 3 Mobile _ 3 Armored MORE THAN TM SUBSTANCES INVOLVED(USTAM70-NAL INFORMA710N-ON CHP 556) H. ❑Yes No SPECIAL STUDIES-LOCAL USE SPECIAL STUDIES STATE USE I 1. A B C D 2. A BCD 3. A R C D 4. A B C D 5. A B C D 6. A B C D HAZMAT IDENTIFICATION SOURCES(CHECK BEST DESCRIPTION(S)) HAZMAT CASUALTIES NO.OF NO.OF NO. J 19 Onsite fire services 58 Tox center J 78 Shipping papers DECONJ INJURIES FATALITIES J 25 Private into source _ 59 Chemtrec _ 87 Computer software EXPOSED 29 Off-site fire services _ 71 DOT manual _ 98 No reference Responding agency 0 0 0 _ 40 On-site non-fire services _ 73 MSDS material used personnel J 60 Off-site non-fire services J 75 Placardstsigns _ 99 Other Others 0 0 0 54 Chemist VEHICLE MAKENEAR 74R26598 ICLE LICENSE NO. STATE f9M OR CAIDOTIPUCIICC NO. COMPANY NAME K Peterbuilt 1993 CA 18 CA1407 Bo ett Petrolium REPORTING OFFICER NAME/RANKILD.NO.(PRINT OR TYPE) DATE COMMENTS ON REVERSE L Don Pela, Sergeant, #4160 09/10/95 []Yes ❑No