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04-08-2005 15:59 From-OES HQ F x i. SA NTO W/C 916-845-8910 T-228 P.001/001 F-965 <br /> : GOVERNOR'S OFFICE OF EMt�NCY SERVICL5 <br /> A <br /> 1.i � Hazardous Materials Spill Report <br /> S <br /> u,, <br /> RATE: 04/08/2005 RECEIVED BY: CONTROL#: <br /> TIME; 1537 OLS- Sibyl Clark OES- 45-2143 <br /> 1 <br /> 08PR- NRC- <br /> 1.a. PERSON NOTIFYING COVERNOWS OES: <br /> 1. NAME. 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/CELL: <br /> Ray Von'Flue San Ioaquin Co,Env.Health 1-2091468-9848 <br /> Dept_ <br /> 1.b. PERSON REPORTING S:PJU(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAC/CELL: <br /> 2, SUBSTANCE TYPE: <br /> r Z.a.SUBSTANCE: b.QTY:—< Amnutu Measure c.TYPE: d.OTHER; <br /> 1. Diesel fuel = Unk Gals) PETROLEUM <br /> 2. - <br /> 3. <br /> e.DESCRIPTION: Pailure in underground primary line has caused this release. This line handles product from 4 <br /> above ground tanks through the underground line to the pumps. Product has gone into a containment sump. <br /> f.CONTAINED: g.WATER INVOLVED: h.WATERWAY: i.DRINKWG WATER IMPACTED <br /> Unknown Unknown <br /> 3. a.INCIDENT LOCATION: Jimco Truck Plaza @1022 Frontage Rd. <br /> b.CITY: c.COUNTY: d.2 : <br /> Ripon San Joaquin County <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE.04/05/2005 b. TIME (MROW: 1000 c.SITE: Service Station <br /> d. YN.RIRIES# e.1±ATALS N. <br /> f.EVACS#: g.CLEANUP BY: <br /> }}`I 0 p Contractor <br /> c Same as_#1,"PFRGUN NpTIFYING OFs <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c. 9-60E#: d.E7t'[.: <br /> Gil 1-2009-6029274 <br /> e.MAIL ADIaRl1SS: f.CITY: g.STATE: h.ZTP: <br /> C,A <br /> 6. NOTIFICATION INFORMATION: <br /> �a.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> �y d.ADMIN. AGENCY; San Joaquin County imergeney Sorvices e.SEC.AGENCY: <br /> �l f.NOTIFICATION LIST_ DOG halt: RWQCBUnit: 5B – <br /> ANCUPA �U�SFw'S '�J DHS-In 0. FOOD&AG LJ OSIiA L USC4 <br /> r�,,rAIR F CSOURCES 6D LI oor, LAN PS h❑PAKKS a REC ❑=01L�V DTSG u C.SLTRANS Ed PAM {G�0FS HIZM•TUNR �❑MC OTHER <br /> RWQCD C CDF a LMSA yL�I OES PLANS UNIT II—SFM <br /> LS EPA D c01,STAL COM Q MMA 065 Pmo 1TSMMM <br />