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Jan 04 06 04: 15p San Joaquin County OES 2094682600 p, 9 <br /> 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-01521 (209)468-3962/3969 01 -7215 <br /> INCIDENT DATE I TIME NOTIFIED TIME COMPLETED DATE COMPLETED <br /> B 12/13/2001 1410 1820 if DIFFERENT FROM <br /> INCIDENT DATE <br /> INCIDENT ADDRESS/LOCATION CITY/COMMUNITY COUNTY ZIP <br /> C River Road west of Wagner Road. Unincorporated San Joaquin <br /> WEATHER TEMP PROPERTY USE SURROUNDING AREA PROPERTY MANAGEMENT <br /> D I 1 CLEAR 55 962 County/City Road 650 Agricultural County <br /> .� RELEASE FACTORS TYPE OF E UIPMENT INVOLVED IMOBILE PROPERTY TYPE <br /> E 31 Abandoned 98 No Equip Involved 98 No Mobile Property Involved <br /> ACTIONS TAKEN <br /> F 41 Remove Hazard; 42 ID/Analysis of HazMat; 44 Establish Safe Area; 47 Decon Area(Clean Up) <br /> 99 Other Material removed by DTSC Contractor <br /> CHEMICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS I CAS NO. <br /> Clan Lab contaminated materials <br /> PHYSICALSTATE PHYSICALSTATE QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENTOF <br /> TORED RELEASED RELEASE <br /> CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER CONTAINER MATERIAL CONTAINER CAPACITY <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 /> STORED RELEASED RELEASE <br /> CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINBI CONTAINER MATERIAL CONTAINER CAPACITY <br /> J <br /> MORE THAN 2 SUBSTANCES INVOLVED? ❑YES ®NO <br /> ADDITIONAL INFORMATION <br /> H Materials removed under DTSC contractor-CLUE#2001- 12-075A. <br /> I.A B C D 2. A B C D 3. A B C D 4. A R C D 5. A BCD 6- A BCD <br /> I SPECIAL <br /> STUDIES LOCAL STATE <br /> USE -- - - — - - - — — — — - - <br /> HAZMAT IDENTIFICATION SOURCES HAZMAT CASUALTIES <br /> PERSONNEL REFERENCE MATERIAL #OF #OF #OF <br /> 40 On-Site Non-Fire 98 No Reference DECONTAMINATED INJURIES FATALITIES <br /> Services Material Used AGERESNCY PERSONNEL NDING0 0 0 <br /> OTHERS 0 0 0 <br /> VEHICLE MAKEJYEAR JVEHICLF LICENSE NO. STATE VEHICLE ID NO.(VIN) CA/DOT/PUCICCNO. COMPANY NAME <br /> K N/A <br /> L REPORTING OFFICER NAME(ID NO.(PRINT OR TYPE) DATE COMMENTS ATTACHED <br /> M Parissi, OES8 12/14/2001 YES <br />