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From:CALIFORHIA STATE WARN:"---GNTR 19188458910 0911r ^''712 15:22 #318 P.0(01111001 <br /> California Emergency Management Ae � O L� <br /> Hazardous Materials Spill Report <br /> DATE: 09/10/2012 RECEIVED BY- CONTROL#: <br /> TANTE: 1517 Cal EMA- Courtland.Ellis Cal EMA- 12-5442 <br /> 10SPR- <br /> <br /> <br /> 1.b. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAGICELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY: Antoruit Measure e.TYPE: d.OTHER: e. PIPELINE f. VESSEL <br /> >=< >=300 Tons <br /> 1.Diesel - 1/2. Gal(sl PETROLEUM Q Yes M No Q Yes 0 No <br /> 2. = Q Yes 0 No O Yes 0 No <br /> 3• = O Yes *No Q Yes 0 No <br /> g.DESCRIPTION. A inechanical failure caused this release to ilia asphalt only and no waterways were affected. <br /> h.CONTAINED: i.WATER j.WATERWAY: k.DRINKING WATER IMPACTED <br /> INVOLVED: <br /> Yes No No <br /> 1.KNOWN EVIPACT None <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 15I5 MerehanbBusiness Mechar]ical <br /> e. .€s'JUM_€+•S €:.HAT,,k1.1T'Y ga.I:;VACUATION h..f:LI ANI7P BY: <br /> d Yes 0 No ©Yes 0 No 0 Yes *No Reporting Party <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION ENFORMATION: - <br /> Ia.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADAHN.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 ❑AIR RESOURCES BD ❑DPR ❑Cal EMAHAZMATuNrr❑SFM N CO/F Filth <br /> N DFG-OSPR ❑CALTRANS ❑EB PARKS ❑cal EMAPLANS UNIT ❑UCSB ❑OTHER <br /> N DTSC ❑CALFME ❑EMSA ❑Cal EMA REG ❑Uama ❑DFG/OSPRMISU <br /> N RWQCB ❑COASTAL COM ❑FEMA ❑OSHA ❑USCG <br /> NUS EPA ❑CDPH-D.O. ❑FOOD&AG ❑PARKS&REC ❑COMP <br /> N USFWS ❑DOG ❑LANDS ❑PUC ❑cwi-nth <br /> CONFIDE PTf L41 <br /> REn S <br /> Warning.centsr;vaps.sairaua.ca,Gv;Rt PRC ?i,Y_4.�s0V;DTSCXRggMaii.c0M <br /> daustinna,.rateri oar3s.ca.;oY;fw8cemaspilYrptt�fws.;ov;ggiuth@waterboard.s.co.gov;mwaiton @vi aterboards.ca.gov; <br /> RCervantesC,tvaterboarzis.co.gov;srraeeks��yateaboards.ca.gov <br />