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Sep 22 06 09: 41a San Joaquin County OES 2094682600 p. 8 <br /> CALIFORNIA HAZARDOUS MATERIALS INCIDENT REPORT SYSTEM <br /> AAGENCY NAME AGENCY ID NO. INCIDENT NO. AGENCY TEL NO. OES CONTROL NO. <br /> San Joaquin OES 39807 XSJ-01577 (209)468-3962/3969 02-1349 <br /> INCIDENT DATE TIME NOTIFIED TIME COMPLETED DATE COMPLETED <br /> B 3/11/2002 1040 1150 If DIFFERENT FROM <br /> INCIDENT DATE <br /> INCIDENT ADDRESS/LOCATION CITY/COMMUNITY COUNTY ZIP <br /> C I <br /> NIS Stockton Street at the intersection of Thornton Rd. Unincorporated San Joaquin 95220 <br /> WEATHER TEMP I PROPERTY USE SURROUNDING AREA PROPERTY VIA\AGEMENT <br /> D I CLEAR 65 962 County/City Road 400 Residential County <br /> RELEASE FACTORS ITYPE OF EQUIPMENT[\VOLVED IMOBILEPROPERTY TYPE <br /> E 50 Mechanical Failure 97 Vehicular Fuel System 20 Freight Veh/Road <br /> ACTIONS TAKEN <br /> F 71 -Investigate fuel spill incident;99-Contact Environmental Health and give instructions to County Public Works <br /> CHEMICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS I CAS NO. <br /> —' Diesel Fuel 1993 3 Flammable Mixture <br /> Liquids <br /> PHYSICAL STATE PHYSICAL STATE QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF <br /> TORED RELEASED RELEASE <br /> 2 Liquid 2 Liquid <5 Gallons 3 Ground 6 Property of Origin <br /> CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER CONTAINER MATERIAL CONTAINER CAPACITY <br /> 3 Mobile 21 Tank or Silo 30 Above Ground 2 Aluminum & Alloys 110 Gallons <br /> G <br /> CHEMICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS CAS NO. <br /> PHYSICALSTATE PHYSICAL STATE I QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENTOF <br /> STORED RELEASED RELEASE <br /> CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER TONTAINER MATERIAL CONTAINER CAPACITY <br /> MORE THAN 2 SUBSTANCES INVOLVED? ❑YES ® NO <br /> ADDITIONAL INFORMATION <br /> H <br /> LA BCD 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 /> HAZMAT IDENTIFICATION SOURCES HAZMAT CASUALTIES <br /> PERSONNEL REFERENCE MATERIAL #OF #OF #OF <br /> 29 Off-Site Fire DECONTAMINATED INJURIES FATALITIES <br /> J 99 See Comments RESPONDING <br /> Services Page AGENCY PERSONNEL p 0 0 <br /> OTHERS 0 0 0 <br /> [VEHICLE MAKE.YEAR IVERICLE LICENSE NO.ISTATE VEHTCLE 1D NO. (VIN) CAMOT/PUC/ICC NO. COMPANY NAME <br /> K 95 Freightliner AE0306 Idaho T 313385 SMX Incl <br /> L REPORTING OFFICER NAMF/ID NO.(PRINT OR TYPE) DATE COMMENTS ATTACHED <br /> A Bentley,OES5 3/11/2002 YES <br /> d <br />