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run;CALIFORHIA STATE WARNING CNTR 1916$458910 05/05/2012 09:40 #164 P.0011002 <br /> Callibrnia Emergency Management Agency <br /> Hazardous Materials Spill Report <br /> DATE: 05/05/2012 RECEIVED BY: CONTROL#: <br /> TIME: 0924 Cal EMA- Kavin Godwin Cal EMA- 12-2691 <br /> OSPR- NRC- <br /> La. PERSON NOTIFYING Cal EMA: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Est: S.PAG/CELL: <br /> Mike Young Super Store Industry 209-858-3468 209-815-3440 <br /> i.b. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext~ 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY: Anusol Meg— C.TYPE: d.OTHER: e. PIPELINE f. VESSEL <br /> '=` >=300 Tons <br /> 1.Hydraulic Oil = 30-44 Gal(s) PETROLEUM O Yes *No O Yes * No <br /> 68 <br /> 2. — O Yes *No O Yes * No <br /> 3. O Yes *No O Yes * No <br /> g.DESCRIPTION: Caller states a filter cracked on the ice-maker machine at the Grocery Distribution Center. <br /> Caller states substance released to a floor drain that goes to the sewer. Caller stated that the <br /> maintenance engineers found the drain clogged and most of the released hydraulic oil will be <br /> recovered. <br /> h.CONTAINED: i.WATER j.WATERWAY: k.DRINKING WATER EMPACTED <br /> INVOLVED: <br /> Yes Unknown Sewer Line No <br /> L KNOWN IMPACT unknown <br /> 3. a.INCIDENT LOCATION: 16888 Mc Kindley Ave <br /> b.CITY: C.COUNTY: d.ZIP: <br /> 1:2Lh= San Joaquin County 95330 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME tmililaty): C.SITE: d. CAUSE <br /> 'evasms 0915 1�&rchant/Business Mechanical <br /> e. INJURIES L FATALITY g.EVACUATION h.CLE iINETP BY: <br /> O Yes *No O Yes *No O Yes *No Responsible Party <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> Super Store Industry 209-858-3468 <br /> e.MAIL ADDRESS: f.CITY: g.STATE: h.ZIP: <br /> 16888 M. c Kindley Ave Lathrop CA 95330 <br /> 6. NOTIFICATION INFORMATION: <br /> �.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADMEN.AGENCY: San Joaquin County Fzmgency Services e.SEC.AGENCY: <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RWQCB XML 5B <br /> ®AAICUPA ❑AIRRESOURCES SD ❑DPR ❑Cal M AF1APMAIVNR'❑MU ®C.T Mth <br /> IRDFG-OSPR ❑CALTRANS ❑ES PARK= ❑Cal EMAPLAM M= ❑UCM ❑OTHER <br /> ®DISC ❑CALERE ❑EJWA ❑Cal EMARFA ❑Uma& ❑DFGMM WWU <br /> RWQCB ❑comrAL CORS ❑FEMA ❑OSHA 0 usco <br /> US EPA ❑CDPH-D.O. ❑FOOD A AG ®PARK$&3= ❑Caw <br /> [Ruff= ❑lx* O LANDS ❑PUC ®Co/Fnkh <br /> CONMENTIAL <br /> RX&L RKS: <br /> Wamffig.renterg ops.calems.ce..go�v;;LAT.BCD0Pnbner� 01RCG.ma;�RRC(TEPAXOV;ttCCA19med$@U�:g.mu; <br /> Received Time May. STT :4 I lilY1"W0 L 4jC0���' oa� pnratssxx ommarakra llrrnscS.mil <br />