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From:CAL I FORH I A STATE WARN I N*TR 19168458910 08/ "Oil 16:10 #785 P.001/001 <br /> California Emergency Management Agency <br /> (Hazardous Materials Spill Report <br /> DATE: 08/12/2011 RECEIVED BY: CONTROL#: <br /> TIlVIE: 1605 Cal EMA- Ronald Demayo Cal EMA- 11-4804 <br /> OSPR- NRC- <br /> <br /> <br /> Lb. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY: Amount Measure c.TYPE: d.OTHER: e. VESSEL <br /> >=300 Tons <br /> 1.Diesel Fuel = 2 Gal(s) PETROLEL 1/1 O Yes 0 No <br /> 2. = OYes * No <br /> 3. - O Yes + No <br /> Caller states a cracked fuel line on a refrigeration van resulted in the release of substance <br /> onto concrete. The product absorbed and.put into a petroleum recovery barrel. <br /> f.CONTAINED: g.WATER h.WATERWAY: i.DRINKING NATER IMPACTED <br /> INVOLVED: <br /> Yes No <br /> j.KNOWN IMPACT None <br /> 3. a.INCIDENT LOCATION: 1.6888 MciKinley Avenue <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Lathrop San Joaquin County 95330 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (Military): C.SITE: d. CAUSE <br /> 08/12/2011 0720 Other Mechanical <br /> e. INJ ;RIES f IATA-LITY g.EWACU€ TIQN 11.CLE A;-\'U!'P."9y: <br /> O Yes *No O Yes 9 No O Yes *No Reporting Party <br /> <br /> <br /> <br /> b. NOTIFICATION INFORMATION: <br /> Ia.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADNIIN.AGENCY: San Joaquin County Emergency Services e.SEC.AGENCY: <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: RWQCB Unit: 5B <br /> N AA/CUPA ❑An2 RESOURCES BD ❑DPR ❑Cat EMAHAZMATuNTr❑SFM ❑OTHER <br /> N DFG-OSPR ❑CALTRANS ❑EB PARKS ❑cal EMA PLANS UNIT ❑USMMS ❑DFG/OSPRIMSU <br /> N DISC ❑CDF ❑EMSA ❑Cal EMAREG ❑USCG <br /> N RWQCB ❑COASTAL COM ❑FEMA ❑OSHA ❑c.Avp <br /> NUS EPA ❑CDPH-D.O. ❑FOOD&AG ❑PARKS&REC ❑c./Hith <br /> N USFWS ❑DOG ❑LANDS ❑PUC ❑C&E-Hlth <br /> CONMIDENTLU, <br /> a�E;ar,�zE.s <br /> IIraT�iBg.center'rr)ops.calrrna.ca.gov;.�.9_RR��r FF'A.>iOZ';D'i'ss .E: aiv r�aii.ca�m <br /> inwraltor,Vw 1Q.erboards.t.a.go <br />