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O DLJ <br /> Kimberly Blackwell EH o Ll <br /> From: Warning Center[Warning.Center@ops.calema.ca.gov] <br /> Sent: Monday, November 19, 2012 12:13 PM <br /> To: Kimberly Blackwell[EH] <br /> Subject: Hazardous Materials Spill Report: Cal EMA Control#:12-7005 <br /> California Emergency Management Agency <br /> Hazardous Materials Spill Report <br /> DATE: 11/19/2012 RECEIVED BY Cal EMA: Ronald Demayo J Cal EMA <br /> CNTRL#:12-7005 <br /> TIME: 1207 RECEIVED BY OSPR: I NRC#: <br /> 1.a. PERSON NOTIFYING Cal EMA <br /> 1. NAME: Kelly Durrer 1 2. AGENCY: Super Store Industries <br /> 3. PHONE#: 559-410-2020 1 4. EXT: 1 5. PAGER#: <br /> 1.b. PERSON REPORTING SPILL (If different from above): <br /> 1. NAME: 2. AGENCY: <br /> 3. PHONE #: 4. EXT: . 1 5. PAGER M <br /> 2. SUBSTANCE TYPE: <br /> a. SUBSTANCE: 1 b.QTY: 1 Amount 1 Measure 1 c. TYPE 1 d. OTHER 1 e. <br /> PIPELINE /f. Vessel Over=> 300 tons <br /> 1. Antifreeze 1 =121 Gal(s) 1 CHEMICAL/ 1 No/ No <br /> ------------------------------------------------------- <br /> 2. <br /> --------------------------------------------------------- <br /> 3. <br /> g. DESCRIPTION: Caller states the hose line on a semi truck burst due <br /> to unknown causes which resulted in the release of substance onto blacktop. <br /> On-site personnel used absorbents to clean up the release and then placed it into a hazardous waste drum. <br /> h. CONTAINED: Yes I i. WATER INVOLVED: No <br /> j. WATERWAY: I k. DRINKING WATER IMPACTED: <br /> I. KNOWN IMPACT: None <br /> 3.a. INCIDENT LOCATION: Driveway leading into facility located at 16888 <br /> McKinley Avenue <br /> b. CITY: Lathrop I c. COUNTY: San Joaquin County I d. ZIP: 95330 <br /> 4. INCIDENT DESCRIPTION: <br /> a. DATE: 11/19/2012 b. TIME(Military): 1110 c. SITE: Other I d. CAUSE: Unknown e. INJURIES: <br /> No I f. FATALITY: No g. EVACUATIONS: No h. <br /> CLEANUP BY: On-site personnel. <br /> e. INJURIES #: I f. FATALS #: ( g. EVACS#: <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> i <br />