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CALIFORNIA HAZARDOUS MATERIALS INCIDENT REPORT SYSTEM <br /> AAGENCY NAME AGENCY ID NO. INCIDENT NO. AGENCY TEL NO. DES CONTROL NO. <br /> San Joaquin IDES 39807 XSJ-01056 (209)468-3962/3969 00-2176 <br /> INCIDENT DATE TIME NOTIFIED TIME COMPLETED DATE COMPLETED <br /> B 5/16/2000 0930 1145 If DIFFERENT FROM <br /> INCIDENT DATE <br /> INCIDENT ADDRESS/LOCATION CITY/COMMUNITY COUNTY ZIP <br /> C 1 <br /> 4100 E.Fremont Street Stockton San Joaquin 95215 <br /> WEATHER I TEMP rPROPERTY USE I SURROUNDING AREA 1PROPERTY MANAGEMENT <br /> D 1 CLEAR 500 Mercantile,Bus 400 Residential Private <br /> f RELEASE FAC70 ITYPE OPEQUIPMENT INVOLVEDMOBILE PROPERTY TYPE <br /> E 50 Mechanical Failure 96 Hazmat Transfer Equip 98 No Mobile Property Involved <br /> ACTIONS TAKEN <br /> F 63 Notify Other Agency, 64—provide public info,71_Investigate. <br /> F <br /> MICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS CAS NO. <br /> oline 1203CAL STATE PHYSICAL STATE QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF <br /> D RELEASED RELEASE <br /> quid 2 Liquid <1 Gallon 3 Ground 6 Property of Origin <br /> AINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER CONTAINER MATERIAL CONTAINER CAPACITY <br /> 9 See Comments Page <br /> G CHEMICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS CAS NO. <br /> PHYSICAL STATE PHYSICAL STATE QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF <br /> it STORED RELEASED RELEASE <br /> CONTAINER DESCRIPTION 1CONTAINERTYPE LEVEL OF CONTAINE CONTAINER MATERIAL CONTAINER CAPAC <br /> MORE THAN 2 SUBSTANCES INVOLVED? ❑YES ®NO <br /> ADDITIONAL INFORMATION <br /> H <br /> l.A B C D 2. A B C D 3. A B C D 4. A B C D 5. A B C D 6. A B C D <br /> I SPECIAL <br /> STUDIES LOCAL STATE <br /> USE - - - - — — — — — _ _ _ <br /> L <br /> HAZMAT IDENTIFICATION SOURCES HAZMAT CASUALTIES <br /> PERSONNEL REFERENCE MATERIAL #OF #OF #OF <br /> ` JDECONTAMINATED INJURIES FATALITIES <br /> RESPONDING N/A N/A N/A <br /> AGENCY PERSONNEL <br /> OTHERS N/A N/A N/A <br /> r. EHICLE MAKE/YEAR IVEHICLE LICENSE NO.ISTATE VEHICLE ID NO. (VIN) CA/DOT/PUC/ICC NO.I COMPANY NAME <br /> K I N/A N/A I N/A I N/A N/A N/A <br /> I. IREPORTING OFFICER NAME/ID NO.(PRINT OR TYPE) DATE COMMENTS ATTACHED <br /> R Lopez,OES7 <br /> 5/17/2000 YES <br />