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10-15-2008 1.0:23 FrorrDES HQ SACRAMENTO W/C 918445-8910T-747 D1/001 F-875 } <br /> ;S GOVERNOR'S OFFICE OF E <br /> SERVICES <br /> Hazardous Materials Spill <br /> 0 <br /> r/ <br /> FA E.- 10/15/2008 RECEIVED BY: CONTROL#: <br /> TIMi:. 1011 OES- Dana Petcrscn OES- 08-7442 <br /> OSPR- NRC- <br /> La. PERSON NOTIFYING GOVERNOR'S OES: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/CELL: <br /> Melissa Martin 'Veeder Root 336=315-2746 <br /> l.b. PERSON REPORTING SPILL(If different frons above): <br /> 1. NAME: 2. AGENCY; 3. PHONEO; 4.Ext. 5.PAG/CELL: i <br /> 2. SUBSTANCE TYPE: <br /> Z.a.SUBSTANCE: b.QTY:— .Amount Measure c.TYPE: d.OTHER, <br /> 1. Gasoline - 3 Galls) PETROLEUM <br /> 3. <br /> e.DESCRIPTION: Customer error at a fueling station <br /> L CONTAINED: g:WATER INVOLVED: h.WATERWAY: i.DRINKING WATER IMPACTED <br /> Yes No r <br /> 3. a.INCIDENT LOCATION: ,6425 Noah Pacific <br /> b.CITY: e.COUNTY. d.ZIP,- <br /> Stockton <br /> IP;Stockton San Joaquin County 95207 , <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATL:10/I5/2008 b. TIME (MEwfy)-1048 C.SITE: Service Siation <br /> d. INJITRIES## e.FATALS#: L E'VACS#: g.CLEANUP BY.- <br /> 0 <br /> Y:0 0 0 Reporting parry <br /> Same as#1.'1 PERSON NOTIFYING OEs" f <br /> S. SUSPECTED RESPONSIRLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#; d.EXT.: ' <br /> Safeway 209.472.8600 1219 <br /> e.MAIL ADDRESS; L CITY: g.STATE: h.GIP: <br /> 6425 North Pacific Stockton CA 95207 <br /> 6. NOTIFICATION INFORMATION: <br /> �a.ON SCENE: b.OTIUR ON SCENE: e.OTHER NOTIFIED; <br /> d.ADMIN.AGENCY: ,San Joaquin Counry-Emergency Samccs e.SEC.AGENC`Y': <br /> f.NOTIFICATIONI�1 LIST: DOG Unix: RWQCB�UL1it: SS <br /> rZr AA�CUPA 7�11 USFWS U CDPtt-D-O I❑F9MA ❑4kS N£G - LJIUSMMY L OTHER <br /> ht1J DFGOSPR f❑�AIA RP.,SUUIrCk.S LID❑1� fL7 Pool)&nC II.-I OS11A ❑USCC <br /> DTSC IU CALTKANS E❑DPP. I, I LANDS If ��PARILS g RLTC ❑ca" <br /> UKwQCfi IL J''CDP LJ Ea PARKS U OWN 4AZMATVNIT IJ PUC U Ca mo <br /> fq <br /> t'•1 US EPA I__I CDASTAL.COM ❑SMSA ❑ons PLANS LINT ❑SFM ❑CaS-Hlgs <br /> I <br />