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REVIEWERS NAME, RANK, AND ID NUMBER DATE <br /> <br />DATE <br />05/13/2018 <br />c <br />STATE OF CALIFORNIA <br />DEPARTMENT OF CALIFORNIA HIGHWAY PATROL <br />HAZARDOUS MATERIALS INCIDENT REPORT . <br />CHP 407E (Rev. 3-15) OPI 062 Refer to HPM 84.2, Chapter 2 <br />OES CONTROL NUMBER <br />18-3089 <br />COLLISION REPORT <br />No A Yes NUMBER 9266-2018-00575 • <br />HAZMAT CASUALTIES NO. EXPOSED/ <br />DECONNED <br />NO. <br />INJURED <br />NO. <br />KILLED <br />CITY <br />Unincorporated <br />JUDICIAL DISTRICT <br />Manteca <br />PHOTOGRAPHS BY <br />Sgt. Rickman, <br />I NONE <br />14921 ID <br />AGENCY PERSONNEL 0 0 0 COUNTY <br />San Joaquin <br />NCIC <br />9266 <br />HAZMAT PLACARDS DISPLAYED <br />Yes @ No OTHERS 0 1 0 <br />INCIDENT DATE (MIWDD/YYYY) <br />05/13/2018 <br />INCIDENT TIME <br />0338 HOURS <br />TIME CALTRANS/COUNTY ROADS NOTIFIED <br />0416 HOURS <br />TIME O.E.S. NOTIFIED <br />0902 HOURS <br />STATE HIGHWAY RELATED <br />No 4 Yes. • <br />INCIDENT OCCURRED ON <br />Southbound I-5 <br />III AT INTERSECTION VVITH Kasson Road Overcrossing North of OR <br />MILEPOST INFORMATION <br />11.07 feet North of Kasson Road Overcrossing " <br />GPS COORDINATES <br />LATITUDE 37.753697° LoNorruDE421.343971° <br />NAME (FIRST, MIDDLE, LAST) <br />James Christensen Randall <br />DRIVER'S LICENSE NUMBER <br />D10165491 <br />STATE <br />AZ <br />VEH. YEAR <br />2017 <br />MAKE <br />Peterbilt <br />LICENSE NUMBER <br />2418170 <br />STATE <br />IN <br />STREET ADDRESS VEH. . <br />1649 Nottingham Drive <br />YEAR <br />2013 <br />MAKE <br />Wabash <br />LICENSE NUMBER <br />P547498 <br />STATE <br />IN <br />CITY/STATE/ZIP CODE <br />Bullhead City, AZ 86442 <br />VEH. YEAR MAKE LICENSE NUMBER STATE <br />HOME PHONE <br />951-588-3103 <br />BUSINESS PHONE <br />866-597-4266 <br />CARRIER NAME <br />CTI Central Trucking Inc. <br />HAZMAT IDENTIFICATION SOURCES (CHECK <br />s <br />services <br />services <br />ALL THAT APPLY) <br />Control Center <br />Data Sheet <br />papers <br />Response Guidebook <br />material used <br />11930 <br />REGISTERED OWNER <br />CTI Leasing LLC <br />III SAME AS DRIVER <br />, On-site fire services' <br />Private info source <br />Chemtrec <br />Poison OWNERS ADDRESS <br />N. Hartman <br />. SAME AS DRIVER . <br />IN 46124 Off-site fire services Safety Drive Ste: A Edinburgh, <br />On-site non-fire Placards/Signs VEHICLE IDENTIFICATION NUMBER <br />IXPBD49X8HD355327 Off-site non-fire Shipping <br />Computer software Emergency <br />VEHICLE TYPE <br />25 131 <br />CA NUMBER <br />3609 <br />DOT NUMBER <br />268896 <br />Chemist No reference <br />. Other <br />CHEMICAL/TRADE NAME <br />Diesal Fuel <br />UN <br />NUMBER <br />1993 <br />DOT HAZARD <br />CLASS <br />3 <br />QUANTITY RELEASED <br />(LBS., GAL, ETC.) <br />20 Gallons <br />EXTENT OF RELEASE <br />Outside vehicle <br />PHYSICAL <br />STATE STORED <br />Liquid <br />PHYSICAL STATE <br />RELEASED <br />Liquid <br />CONTAINER TYPE <br />Vehicular fuel tank <br />CONTAINER CAPACITY (LBS., GAL., ETC.) <br />100 Gallons <br />CONTAINER MATERIAL <br />Aluminum/Aluminum alloys <br />LEVEL OF CONTAINER <br />Above ground <br />CHEMICAL/TRADE NAME UN <br />NUMBER <br />DOT HAZARD <br />CLASS <br />QUANTITY RELEASED <br />(LBS., GAL, ETC.) <br />EXTENT OF RELEASE PHYSICAL <br />STATE STORED <br />PHYSICAL STATE <br />RELEASED • <br />CONTAINER TYPE CONTAINER CAPACITY (LBS., GAL., ETC.) CONTAINER MATERIAL LEVEL OF CONTAINER <br />PROPERTY USE <br />Freeway <br />SURROUNDING AREA <br />Open land <br />PROPERTY MANAGEMENT <br />State <br />RELEASE FACTORS <br />Collision/Overturn <br />Fire/Explosion <br />EQUIPMENT TYPE INVOLVED <br />Vehicle fuel system <br />HAZMAT CONFIRMED <br />@ Yes • No <br />CITATION ISSUED OR COMPLAINT TO BE FILED PRIMARY CAUSE OF INCIDENT <br />23152 (A) VC <br />OTHER HAZARDOUS MATERIALS VIOLATIONS (NON-CAUSATIVE) <br />0 Yes i1 No • Not determined 1 Violation I Yes No <br />Other party/vehicle involved caused collision <br />DID WEATHER CONTRIBUTE TO CAUSE OR SEVERITY OF INCIDENT? <br />WEATHER <br />Other Code violation <br />Other cause I Yes a No <br />ELEMENTS (OUTLINE THE FOLLOWING ON A CHP 556. INCLUDE ADDITIONAL INFORMATION AS NECESSARY) <br />Z Sequence of events <br />Z Road closures <br />ID Evacuation details <br />Z Environmental impact <br />E Cleanup actions <br />Z Actions of other agencies <br />[3] CHP On-scene Personnel (name, rank, ID <br />number, function, exposure, hours) <br />COMPLETE THE FOLLOWING <br />Z Incident Action Plan El Site Safety Plan Z Proposition 65 Letters: County Health/County Board of Supervisors <br />DATE AND TIME SCENE DECLARED SAFE BY WHOM (NAME, TITLE AND AGENCY) <br />05/13/2018 1420 HOURS Garrett Backus, Environmental health Specialist, San Joaquin Environmental Health Department <br />PREPARER'S NAME, RANK, AND ID NUMBER <br />Robert Rickman, Sergeant, 14921 <br />Destroy Previous Editions An Internationally Accredited Agency Chp407E_0515.pdf