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OR San Francisco -11) Water?owe-Sewer WSTD Hazardous Material Incident/Release SWvlces of the San Francisco PublicUtilities Commission Assesment Form Instructions: Complete this form for a hazardous material incident or release at a Regional Water System Facility. The following is a tool to be used for assessing if a release is potentially reportable as required by Chapter 6.95 of the California Health and Safety Code. This assessment tool does not replace good judgement, Chapter 6.95, or other state or federal release reporting requirements. If an emergency, call 9-1-1. Incident/Facility Location: Tesla Treatment Facility Date of Occurrence: $/5/19 Time: 1350 Hazardous Material (e.g. `25% Sodium Hydroxide): Mercury Quantity(gal, Ib): 2.3 grams Location (e.g. `Discharge pipe inside second containment): Lamp 2-2 in UV 2010. Water was contained in baker tanks Questions for Incident Assessment YES NO Was anyone killed or injured, or did they require medical care or admitted to ❑ a hospital for observation? Did anyone, other than employees in the immediate area of the release, ❑ evacuate? Did the release cause off-site damage to public or private property? Is the release greater than or equal to a reportable quantity? (RQ under 40 ❑ CFR 302.4 Was there an uncontrolled or unpermitted release to the air? Did an uncontrolled or unpermitted release escape secondary containment, or extend into any sewers, storm water conveyance systems, utility vaults and ❑ conduits, wetlands, waterways, public roads, or off-site? Will control, containment, decontamination, and/or clean up require the ❑ assistance of federal state countV, or municipal response elements? Did the release or threatened release involve an unknown material or contain 1:1an unknown hazardous constituent Is the incident a threatened release? (a condition creating a substantial probability of harm that requires immediate action to prevent, reduce, or ❑ mitigate damages to persons, property! or the environment. Is there an increased potential for secondary effects including fire, explosion, F-1line rupture, equipment failure, or other outcomes that may endanger or v cause exposure to employees, the general public, or the environment? If the answer is YES to any of the above questions, report the release to the California Governor's Office of Emergency Services Warning (Cal OES) Center and to your local CUPA. Use the WSTD Hazardous Material Incident/Release Reporting Form. Assessment prepared by: Justin Sibbring Chief Stationary Engineer Assessment reported to System Operations Manager or designee: YES ❑ NO Date: 8/7/19