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6jk,jw�- 0 #M <br /> Datetime inci([ent bel*,.. ,,.- a0091"' <br /> i :Oqfto� <br /> Dateltme incident en--. 75�, �f­x_!; <br /> / <br /> Name of Shipper/Indua­ <br /> r7__ . <br /> AddressRa 11 M Sh i.., Nearest city. distance <br /> Type of Incident Me'. -rials Number of items Container State of Matter <br /> C C_ 0 t� C") -:1 <br /> Vehicle in Accident D;21 Fire C:1 td n q n\-n �j -d �_g �_3 �_3 <br /> = a) T 0 '-i \-n 0 -1 T1 0 a 0 �1 0 (D F— 0 is <br /> ro) 0 (D 0 M 0 M <br /> Leak in Moving Vehicl- --I Explosion — Ct 10 = <br /> 0 0 ct c+ Oq H (D >V :3 0 M <br /> Ln W M 0 W P;;' (D H CL. <br /> Fell frim Vehicle t= Reaction =C+— M -- CL F-j mati <br /> Abandoned Ma-leria None M M (n (D 0 Cr Gq (D CD 'M <br /> 0j <br /> Fixed Facili,;y <br /> (D <br /> ame of Material Anount released —61 <br /> Check here if there- -are more7 listed on the back of this page. ❑ <br /> Is there a Manifest c7 MSDS?= yes no. If so please attach a copy to this form. <br /> B. Environmental (chenk at least one from each column) <br /> F7 Rural Off Road <br /> ?,—.1 F1 Bridge Did Materials FT Wind <br /> ❑ Suburban j-1 n t y Ro a d E:j Cirve affect 2E-Air ❑ Rain <br /> Q Co)=ercisl i !sighway/Freeway ❑ Steep incline ❑ Water ❑ Fo E. <br /> Industrial i­j4 2ty street ❑ Tinnel Ground F- <br /> 1. _j Snow, ice <br /> Ll Structure Nene � Human 5n Heat <br /> Other Other (explain) D Animal 0 Fair, or not <br /> ❑ Vegetation a factor <br /> No ne LX7 JAIA,&-t <br /> C. Activities �n the Scen_e_TCheck all of the boxes applicable) <br />❑ Barriers Establishtt,, 12rCleen up_ done *oy Z Contain and Removc <br /> Road Restricted Address/phone = Reaction <br />❑ Road Closed hr" 17 Initial contain- z- eww,&O, ❑ Absorbticn <br /> Evacuation C ment done by <br /> 70 ❑ Sweepdown <br /> Hospitalized aue TxLjsure Address rj Washdown <br /> ❑ a <br /> Ci-vilians Phone and nd Ll-ovel <br /> Re.3pondi,:�g —T, Wind <br /> ,�,ons <br /> AgancyZapel� ��6452 �? Evaperaticn <br /> Decontamination of(� _nosed = liesponaers Civilians E] Animals C::j Other --- <br /> D. Responding agencies 'Uneck all agencies at ,he scene. -HazMat=SDecial team, ProEqu=Res;. i7rator.-i`,_ <br /> Local Hazl',atl ProEqu County HazMat., ProEqu State HazM1at Pro Ecu <br /> Fire ;_ t7x Fire CDF 0 ❑ <br />❑ Police Sheriff CHP El i= <br />--1 Health Health <br /> I Health <br /> Road Dept Road Dept Cal-Trans <br />❑ Public works n F-1 Public Works Fish/Game ❑ <br /> C] Agriculture Federal <br />❑ Parks Dept, ❑ [:I Forest Sery <br />❑ Other C Other Q, �s Coast Guard L7 d <br /> ❑ ERDA ❑ M <br /> ❑ EPA ❑ <br /> Perscn making this rep:7,rt Agency _f4t <br /> - 9 <br /> Address ,PQ. Xo,< 10e Da t e of Re po,rf /;,I- e- k-r- <br /> 0�5—_7&71 Phone <br /> Nara ti-ve/c:)r-jr.e;,ts A�,w <br /> UZ 5-4. <br />