Laserfiche WebLink
EMERGENCY INCIDENT REPORT <br />Company Name: HOLT_ RUBBER CO. iNC. Phone: (209) 368 7171 Address: 1129 S. Sacramento St. Lodi• CA. 95240 <br />County: San Joaquin Date: Time of Incident: ❑AM ❑Pn'1 <br />Location of Incident: <br />Extent of Emergency: <br />Type of Incident: ❑Fire <br />(Explain exact location within the facility) <br />(Explain or describe the situation) <br />❑Fire/Explosion ❑Chemical Spill ❑Chemical Release into air ❑Occupational Accident <br />Cause of Emergency: mc* orage Tank/Drum Leak ❑Process Release/Spill ❑Fire ❑Explosion ❑other (explain below) <br />Explanation: <br />[dentification of Hazardous Material: Shipping Name: _ <br />Chemical Name: Label Information: <br />Other: <br />CIN m• NA Number: <br />Trade Name: <br />Physical Description of Hazardous Material: ❑Solid ❑Gas ❑Granule ❑Infectious ❑Liquid ❑Powder ❑Radioactive <br />Has material run off site? ❑Yes ❑No (If yes, make all required notifications) <br />Explain amount and location: <br />Environment Affected: <br />:]Storage Area(s) <br />❑Entered Stonn Drain(s) <br />]Unimproved Shoulder <br />❑ Bay/Ocean <br />❑Parking Areas <br />❑Air Release <br />❑Agriculture Land <br />❑Coastal Beach <br />]Threat to environment/wildlife: (Explain) <br />Health: <br />Exposure to Employees: ❑Yes ❑No Number <br />Exposure to Public: ❑Yes ❑No Number <br />Medical Attention: ❑Yes ❑No <br />Evacuation Necessary: ❑Yes ❑No <br />Number of staff evacuated from onsite sources <br />Staff Exposed/Injured: <br />Names: Flospital(s) Transported to: <br />❑Facility Buildings <br />❑ Roadway (private) <br />❑Irr <br />igation Water <br />Employees htjured: <br />Public Injured: <br />Hospitalized: <br />❑Entered Sewers) <br />❑[2oadway (Public) <br />❑Lake/Stream <br />❑Yes ❑No Number <br />❑Yes ❑No Number <br />❑Yes ❑No <br />Number evacuated from onsite sources (if known <br />0 <br />Describe Injuries or Exposure (symptoms) <br />