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��U.S. Department of Tin <br />Research and Special <br />Administration <br />HAZARDOUS MATERIALS Form Approval OMB No. 2137-0039 <br />INCIDENT REPORT <br />According to the Paperwork ReduTon Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control <br />number. The valid OMB control nu bar for this information collection is 2137-0039. The filling out ofthis information is mandatory and will take 96 minutes <br />to com plete. <br />INSTRUCTIONS: Submit this rer ort to the Information Systems Manager, U.S. Department of Transportation, Research and Special Programs <br />Administration, Office of Hazardoi is Materials Safety, DHM-63, Washington, D.C. 20590-0001. If space provided for any item is inadequate, use a <br />separate sheet of paper, identifyinc the entry number being completed. Copies of this form and instructions can be obtained from the Office of Hazardous <br />Materials Website at http://hazmat dot.gov. If you have any questions, you can contact the Hazardous Materials Information Center at 1 -800 -HMR -4922 <br />(1-800-467-4922) or online at http:/ hazmat.dot. gov. <br />1. This is to report: <br />2. Indicate whether this is: <br />3. Date of Incident: 11/2 <br />5. Enter National Response Centel <br />6. If you submitted a report to anotl <br />7. Location of Incident: City: St( <br />Street Address/Mile Marker/Yard <br />8. Mode of Transportation <br />9. Transportation Phase <br />10. Carrier/Reporter Name _ <br />Street _ <br />City <br />Federal <br />11. Shipper/Offeror Name _ <br />Street _ <br />City <br />12. Origin Street _ <br />(if different from <br />shipper address) City_ <br />13. Destination Street _ <br />City <br />14. Proper Shipping Name of Haz <br />15. Technical rrade Name: <br />16. Hazardous Class/ <br />Division: 3 <br />® A) A hazardous material incident ❑ B) An undeclared shipment with no release <br />❑ C) A specification cargo tank 1,000 gallons or greater containing any hazardous materials that <br />(1) received structural damage to the lading retention system or damage that requires repair to a system <br />intended to protect the lading retention system and (2) did not have a release <br />® An initial report ❑ A supplemental (follow-up) report ❑ Additional pages <br />4. Time of Incident (use 24-hour time): 07:05:00 <br />Report Number (if applicable): <br />20. Was the material shipped as a h <br />21. Is this a Toxic by Inhalation (TIH <br />22. Was the material shipped under <br />If yes, provide the Exemption, A <br />23. Was this an undeclared hazardc <br />:r Federal DOT agency, enter the agency and report number: <br />,kton County: San Joaquin State: CA ZIP Code (if known): <br />ame/Airport/Body of Water/River Mile MilePost: 2.44 <br />❑ Air ❑ Highway ® Rail ❑ Water <br />® In Transit ❑ Loading ❑ Unloading ❑ In Transit Storage <br />Inion Pacific Railroad <br />400 Douqlas St., Mail Stop 1040 <br />ID Number <br />State NE ZIP Code 68179 <br />Hazmat Registration Number 062706 002 0040Q <br />City State NE ZIP Code 68826 <br />Paper 5407170 Hazmat Registration Number <br />State ZIP Code <br />State AR ZIP Code <br />Material: ALCOHOLS, N.O.S. <br />17. Identification 18. Packing 19. Quantity <br />Number: UN1987 Group: II Released: 1 Ounces) <br />(E.g. UN2764, NA 2020) (if applicable) (Include Measurement Units) <br />zardous waste? ❑ Yes ® No If yes, provide the EPA Manifest Number: <br />material? ❑ Yes ® No If yes, provide the Hazard Zone: <br />In Exemption, Approval, or Competent Authority Certificate? ❑ Yes ® No <br />:)roval, or CA number: <br />s materials shipment? ❑ Yes ® No <br />Incident Number: 00011750 <br />Car: GATX 201623 <br />