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O.p4utN c SAN JOAQUIN COUNTY - OFFICE OF EMERGENCY SERVICES <br /> HAZARDOUS MATERIALS DIVISION <br /> a: <br /> 222 East Weber Avenue,Room 610, Stockton, CA 95202 <br /> Telephone (209)468-3969 <br /> 4�tFORN\ <br /> ADDENDUM TO <br /> CALIFORNIA HAZARDOUS MATERIALS INCIDENT REPORT <br /> Date Incident Deemed Time Incident Date At Scene Time At Scene SIDES Incident No. <br /> Occured <br /> 4/8/1999 1000 XSJ-00814 <br /> M Initial Information Reported Wind Speed/Direction <br /> Approx. 1 to 2 gallon release due to forklift accident <br /> Reporting Patty Name Address Telephone No. <br /> Todd Hudelson 15658 Escalon Bellota Road 838-3541 <br /> Mid Valley Ag. Service Escalon <br /> Responsible Party Name Address Telephone No. <br /> N <br /> Same <br /> Responsible Party Representative Name Address Telephone No. <br /> Same <br /> OBS HazMat Team OPS Personnel On Scene <br /> Activated <br /> No <br /> Joint Team Activated? Date/time Activated Members On Scene <br /> O No <br /> Fire District Mitigation/Removal Actions <br /> Escalon FD- 1 Material contained and removed by company personnel. <br /> Agency Notifications and/or Referrals <br /> Name of Agency Date of Notification Time of Notification Name of Representative <br /> Notified <br /> P <br /> Reporting Officer Signature CHMIR Filed? Incident Type <br /> Q Yes Fixed Facility, Accident <br /> Page 2 <br />