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C"110/12 Hai _-is Materials Spill Report-12-5442 <br /> California Emergency Aagement Agency <br /> Hazardous Materials Spill Report <br /> DATE: 09/10/2012 RECEIVED BY: CONTROL#: <br /> TIME: 1517 Cal EMA-12-5442 <br /> 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.PIPELINE f. VESSEL <br /> >=300 Tons <br /> 1. Diesel = 1/2 Gal(s) PETROLEUM No No <br /> 2. = No No <br /> 3. = No No <br /> g. DESCRIPTION: A mechanical faRure caused this release to the asphalt only and no waterways were <br /> affected. <br /> h. CONTAINED: i.WATER j. WATERWAY: k. DRINKING WATER <br /> INVOLVED: IMPACTED <br /> Yes No No <br /> 1. KNOWN None <br /> IMPACT <br /> 3. a. INCIDENT LOCATION: 16888 McKinley Ave <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 /> 09/10/2012 1515 Merchant/Business Mechanical <br /> e. INJURIES f. FATALITY g. EVACUATION h. CLEANUP BY: <br /> No No No Reporting Party <br /> 6. NOTIFICATION INFORMATION: <br /> a. ON SCENE: b. OTHER ON SCENE: c. OTHER NOTIFIED: <br /> d. ADMIN. AGENCY. San Joaquin County Energency Services e. SEC. AGENCY: <br /> f. ADDITIONAL COUNTY: g. ADMIN.AGENCY: <br /> h. NOTIFICATION LIST: <br /> DOGUnit: RWQCB Unit:5B <br /> AA/CUPA,DFG-OSPR,DTSC,RWQCB,US EPA,USFWS,Co/E-filth <br /> CONFIRMATION <br /> <br /> <br /> <br /> <br />