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From:OES 9168458910 11/0112008 22:55 #742 P.001/001 <br /> 0 F; S d <br /> GOVERNOR'S OFFICE OF EM <br /> SERVICES <br /> Hazardous Materials SO%�);;t;� <br /> O):m�m);xrsloct <br /> DATE: 11/01"2008 RECEIVED BY: CONTROL#: <br /> TIME: 2246 OES- Tim Tribble GES- 08-7879 <br /> 10SPR- NRC - <br /> La. PERSON NOTIFYING GOVERNOR'S OES: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Eat: 5.PAG/CELL: <br /> Fernando Quan Stockton Fire Department 209-937-13030 <br /> Lb. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Eat: 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY:>=< Amount Measure e.TYPE: d.OTHER: <br /> 1. 3%AFFF = 1350 Gal(s) CHENEC•AL <br /> 2. = <br /> 3. - <br /> e.DESCRIPTION. The onsite fire suppression system at an ARCO service station leaked it's supply of AFFF foam <br /> into a holding tank on site. <br /> f.CONTAINED: g.WATER INVOLVED: h.NVATERAVAY: i.DRINKING\`TATER IMPACTED <br /> Yes No <br /> 3. a.INCIDENT LOCATION: 2700 W. Washington <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Stockton San Joaquin County <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: 11101/200$ b. TIME (Military):2155 e.SITE: Service Station <br /> s€. IN.TE`•Idli;ti# e. T'A`3 A E S#: E'. 3: ',j's. '.S#: g.C I-ANi1. 1 <br /> 0 0 0 Responsible Party <br /> Same as#1."PERSON NOTIFYING OES": <br /> ........................................................................ <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> Mike Peterson :ARCO 209-466-4408 <br /> e.MAIL ADDRESS: f CITY: g.STATE: h.ZIP: <br /> unknown CA <br /> 6. NOTIFICATION INFORMATION: <br /> Ia.ON SCENE: b. OTHER ON SCENE: c.OTHER NOTIFIED: <br /> .Fire Dept. San Joaquin County Environmental Health, <br /> San Joaquin County OES,City of Stockton <br /> Municipal Utilities District <br /> d.ADMIN.AGENCY: San Joaquin County Emergency Services e. SEC.AGENCY: <br /> f.NOTIFICATION LIST: DOG Unit: RwQCB Unit: 5B <br /> ®AN(,--:TA ®USFW° ❑CDPT.-D 0 ❑M4A ❑0:S RF.G ❑us)nts ❑0e7-IrR <br /> ®LFG-:)SPR ❑AIR RPSCURCES BD❑DCG ❑F00L`&AG ❑OSHA ❑USCG <br /> ED-MI, ❑CAL.TRQNS ❑DPR ❑r..Arrrs ❑PA.zKS E RFC ❑CoPJJP <br /> ®rwgm. ❑CDF ❑F_3 P C Ks ❑0L•S HPS VIATUNr ❑?LTC ❑co!M.th <br /> ®US J<-A ❑COASTAL C•014 ❑ENSA ❑OES PLP1dS r1d1T ❑Srm ❑COM-111tL <br />