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• • • CHANGE 1 Q <br /> CALIFORNIA HAZARDOUS MATERIALS INCIDENT REPORT OEs 1/91 DELETE2 Q <br /> AAGENCY NAME AGENCY ID NO. JINCIDENT NO. AGENCY TEL NO. DES CONTROL NO. <br /> San Joaquin County 39807 1 IR-00270 (209)468-3969 015772 <br /> INCIDENT DATE TIME NOTIFIED TIME COMPLETED DATE COMPLETED <br /> B 09/29/96 If DIFFERENT FROM <br /> INCIDENT DATE <br /> INCIDENT ADDRESS/LOCATION CITY/COMMUNITY COUNTY ZIP <br /> C 112001 South Highway 99 Manteca San Joaquin 95336 <br /> WEATHER TEMP I PROPERTY USE I SURROUNDING AREA 1PROPERTY MANAGEMENT <br /> D 1 CLEAR 600 Industrial,Utility 650 Agricultural Private <br /> RELEASE FACTORS TYPE OFEQUIPMENT INVOLVED MOBILE PROPERTY TYPE <br /> H' 00 Undetermined 30 Air Condition/Refrig 98 No Mobile Property Involved <br /> ACTIONS TAKEN <br /> F System shut down and isolated. <br /> CHEMICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS CAS NO. <br /> Anhydrous Ammonia 1005 <br /> HYSICAL STATE PHYSICAL STATE QUANTITY RELEASED NVIRONMENTAL CONTAMINATION EXTENT OF <br /> TORED RELEASED RELEASE <br /> 3 Gas 3 Gas 70 pounds 7 Beyond Property <br /> CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINER CONTAINER MATERIAL CONTAINER CAPACITY <br /> 1,1 Fixed&Insulated 22 Pipe 30 Above Ground 1 Iron, Steel, Alloys <br /> G CHEMICAL OR TRADE NAME DOT ID NO. DOT HAZARD CLASS I <br /> CAS NO. <br /> PHYSICAL STATE PHYSICAL STATE QUANTITY RELEASED ENVIRONMENTAL CONTAMINATION EXTENT OF <br /> STORED RELEASED RELEASE <br /> CONTAINER DESCRIPTION CONTAINER TYPE LEVEL OF CONTAINE CONTAINER MATERIAL CONTAINER CAPACITY <br /> MORE THAN 2 SUBSTANCES INVOLVED? <br /> ADDITIONAL INFORMATION <br /> H NO <br /> 1.A B C D 2. A B C D 3, A B C D 4. A B C D 5. A B C D 6. A B C D <br /> I SPECIAL <br /> STUDIES LOCAL STATE <br /> USE _ — _ — - - _ — — _ — <br /> HAZMAT IDENTIFICATION SOURCES HAZMAT CASUALTIES <br /> PERSONNEL REFERENCE MATERIAL #OF #OF #OF <br /> .T 40 On-Site Non-Fire 98 No Reference DECONTAMINATED INJURIES FATALITIES <br /> RESPONDING ] <br /> AGENCY PERSONNEL <br /> OTHERS <br /> VEHICLE MAKE/YEAR IVEHICLE LICENSE NO.ISTATE I VEHICLE ID NO.(VIN) ICA/DOT/PUC1ICCNO.l COMPANY NAME <br /> K <br /> L REPORTING OFFICER NAME/ID NO.(PRINT OR TYPE)I DATE COMMENTS ATTACHED <br /> M Parissi 09/30/96 No <br />