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C <br />US ecology INCIDENT REPORT <br />General Incident Information <br />Call Date Time (24Hr) Ticket Number Project Number Customer PO <br />5/6/2021 16:30 166456 <br />Company Name Company Contact Name Contact Number Contact Email <br />MA NCNU Donald Clowes 916 275-6816 donald.clowes@norcal.aaa.com <br />Response Team Location Response Supervisor Name Supervisor Phone # Supervisor Email <br />Alameda Dewayne Liles 510 671-4325 dewayne.liles@usecology.com <br />Qualified Individual (if applicable) <br />Same As Above? Company Name QI Contact Name Cal Contact Information <br />Yes If no, complete Phone: <br />section Email: <br />Incident Location / Contact Information <br />Incident Location / Facility / <br />Vessel Name: North Bound Interstate 5 <br />Incident Location Address: Mile Marker 36.5 City: 1 Lodi State/Territory <br />/Province: i California <br />County/Parish: San Joaquin Country (if other than US): <br />On Site Contact Name: Donald Clowes On Site Contact Number: 916 275-6816 <br />Alternate Contact Name: Alternate Contact Number: <br />GPS Coordinates: <br />Truck Driver Name: Truck # Trailer # <br />Customer Incident/ Reference <br />Number: Other: <br />Release Information <br />Material(s) / Product(s) <br />Spilled: Diesel Fuel <br />20 If Other List Below: Amount/Quantity: Unit of Measure: Gallons <br />Type of Spill: Hazardous Soil Multiple (list) Other (list) Spill Surface: <br />Regulatory Notifications' <br />Report Required?: Yes Agency(s) <br />Contacted: <br />San Joaquin Environmental <br />Health <br />Report <br />#(s) <br />UN /DOT Packaging # (s): <br />Sampling / Monitoring <br />Samples Collected? Yes <br />Air Monitoring <br />Performed? No Note: If yes; place data in Attachment C <br />Incident Report Form Version 0