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CALIFORNIA HAZARDOUS MATERIALS INCIDENT REPORT SYSTEM <br /> AAGENCY NAME AGENCY ID NO. JINCIDENT NO. AGENCY TEL NO. OES CONTROL NO. <br /> San Joaquin OES 39807 XSJ-01396 (209)468-3962/3969 <br /> INCIDENT DATE TIME NOTIFIED TIME COMPLETED DATE COMPLETED <br /> B 8/22/2001 1507 If DIFFERENT FROM 8/20/2001 <br /> INCIDENT DATE <br /> INCIDENT ADDRESS/LOCATION CITY/COMMUNITY COUNTY ZIP <br /> C 881 N Shaw Rd. Stockton San Joaquin 95215 <br /> WEATHER I TEMP I PROPERTY USE I SURROUNDING AREAPROPERTY MANAGEMENT <br /> D 0 UNKNOWN 600 Industrial,Utility 600 Industrial, Utility Private <br /> RELEASE FACTORS ITYPE OF EQUIPMENT INVOLVED MOBB.E PROPERTY TYPE <br /> 30 Failure to Control Hazmat 99 See Comment Page 99 See Comment Page <br /> ACTIONS TAKEN <br /> F I 99—Other: Take report only <br /> CHEMICAL OR TRADE NAME DOT ID NO. IDOT HAZARD CLASS CAS NO. <br /> Waste Oil 1270 3 Flammable Mixture <br /> Liquids <br /> HYSICAL STATE PHYSICAL STATE QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF <br /> TORED RELEASED RELEASE <br /> 2 Liquid 2 Liquid 5-10 Gallons 9 Other 6 Property of Origin <br /> V CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER CONTAINER MATERIAL CONTAINER CAPAC <br /> 1-Fixed 21 Tank or Silo 11 Ground Level 1 Iron, Steel, Alloys Unknown <br /> 6. G CHEMICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS I <br /> CAS NO. <br /> PHYSICAL STATE PHYSICAL STATE QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF <br /> V STORED RELEASED RELEASE <br /> CONTAINER DESCRIPTION JCONTAINPR TYPE ILEVELOFCONTAINE]CONTAINER MATERIAL 1CONTAINERCAPACITY <br /> MORE THAN 2 SUBSTANCES INVOLVED? 0 YES ®NO <br /> ADDITIONAL INFORMATION <br /> H <br /> l.A B C D 2. A B C D 3. A R C D4. A B C D 5. A B C D 6. A B C D <br /> F SPECIAL <br /> STUDIES LOCAL STATE <br /> — — — — — — — . _ . <br /> HAZMAT IDENTIFICATION SOURCES HAZMAT CASUALTIES <br /> PERSONNEL REFERENCE MATERIAL #OF #OF #OF <br /> J 99 See Comments Page 99 See Comments RESPONDING DECONTAMINATED INJURIES FATALITIES <br /> Page AGENCY PERSONNEL <br /> OTHERS <br /> EHICLE MAKEfYEAR VEHICLE LICENSE NO.ISTATE IVEHICLE ID NO. VINCA/DOT/PUC/ICC NO.I COMPANY NAME <br /> K I N/A N/A I N/A N/A N/A N/A <br /> L IREPORTING OFFICER NAMEM NO.(PRINT OR TYPE) DATE COMMENTS ATTACHED <br /> A Bentley,OES5 8/22/2001 YES <br />