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rron:0al ENA (State Warning Ge C ;) 9168458910 12/21/ '19 14:26 #344 A.0011001 <br /> oA <br /> Calffomla Emergency Marta ge y <br /> Hazardous Materials .. ?121/2009 RECEIVED BY: CONTROL#: <br /> 410 <br /> Cal EMA- Ruben Rodriguez NR EMA. 09-8491 DEC 2 1 2009 <br /> 1.a. PERSON NOTIFYING Cal EMA: SAN JOPQLif <br /> .IV OOlJI+FiY <br /> 1. NAME: 2. AGENCY: 3. PHONE#. 4.Ext; 5.PAGfZMftNTAL <br /> Casey Wickert Arbor Mobile Home Pads 714-514-8879 <br /> i- .L3 H DEPARTMENT <br /> t.b. PERSON REPORTING SPILL(If different frrooe above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Eat: 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:a=e AMAW mean" c.TYPE: d OTHER: <br /> 1.Sewer 6QQ Gal($) SELVAGE <br /> 2. <br /> 3. _ <br /> e.DFSCRJY[T0N: A private lateral overflowed at the mobile home park Caller states that the on-site marker <br /> and a contractor have recovered most of the release back to the sewage treatment plant, Caller <br /> states NO impact to public waterways,the release was contained completely on site. <br /> E CONTAINED: g.WATER h.WATERWAY: (.DRINKING WATER IMPACTED <br /> INVOLVED: <br /> Yes No On site retention pond No <br /> J.KNOWN IMPACT <br /> 3. a.INCIDENT LOCATION: 19590 North Hwy 99 <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Acampo San J County 95220 <br /> 4.INCIDENT DESCRIPTION; <br /> a.DATE: b. TMIE (Military): c.SITE: d. CAUSE <br /> 12/18/2009 1600 Residence Bloclmge <br /> e. L JURIES f FATALITY g.EVACUATION h.C".LEA.IYLT BY: <br /> Contractor a <br /> A.W* � NOW dw <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> Victot Secheslinglof Arbor Mobile Home 209-329-7539 <br /> Park On-Site Manager <br /> e.MAIL ADDRESS: f.CITY: g.STATE: h.ZIP: <br /> 19690 North Hwy 99 Acampo CA 95220 <br /> 6. NOTIFICATION INFORMATION: <br /> �a.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> RWQCB,County Health <br /> d.ADMIN.AGENCY: San jm*in County e.SEC.AGENCY: <br /> imerpm7&rvices <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> Doc uuu; RWQCB[rale: 53 <br /> AACMA vsm 0CMt-D.0. RRA CWD"Mo u crtzusR <br /> ® ❑AMM=U1t=BD ❑DOO ❑MW AAG ❑a®A ❑usc:o <br /> ®D1= ❑CALTRANs ❑DPR ❑LADS ❑PAW A RRC ❑Odom <br /> ORWQM ❑CDF ❑RB PAM ❑di Z(AW=L-U=❑FW ❑C.4ft <br /> O US IDA ❑comrx c:oM ❑nnA ❑Qd UfAV Mfr UWr ❑!M ❑Cd&M <br /> WamhtQ.cent @ms.ce.lgov;RZ RR[:WA.GOV;0T9C.ZRiXg=a2xom <br />