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Krom:,CALIFORHIA STATE WARNING 01, 19168458910 05/*j!12 09 :40 #164 P-001/002 <br /> California Emergency Management Agency <br /> Hazardous Materials Spill Report <br /> DATE: 05/05/2012 RECEIVED BY: CONTROL#: <br /> TEVIE: 0924 Cal EMA- Kavin Godwin Cal EMA- 12-2691 <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. PIPELINE f. VESSEL <br /> '=` >=300 Tons <br /> 1.Hydraulic Oil = 30-40 Gal(s) PETROLET-ZA 0 Yes 0 No 0 Yes No <br /> 65 <br /> 2. = 0 Yes 0 No 0 Yes No <br /> 3. = 0 Yes `No 0 Yes No <br /> g.DF.SCRIP` P:3N. Caller states a filter cracked on the ice-maker machine at the Grocery Distribution Center. <br /> Caller states substance released to a floor drain that goes to the sewer. Caller stated that the <br /> maintenance engineers found the drain clogged and most of the released hydraulic oil will be <br /> recovered. <br /> h. CONTAINED: i.WATER j.WATERWAY: k.DRINK NG WATER IMPACTED <br /> INVOLVED: <br /> Yes Unlmown Sewer Line No <br /> 1.KNOWN IMPACT Unknown <br /> 3. a.INCIDENT LOCATION: 16888 Me Kindley Ave <br /> b. CITY: c. COUNTY: d.ZIP: <br /> Latlu-op San Joaquin County 9_;330 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIlVIE (Military): G.SITE: d. CAUSE <br /> 05/05/2012 0915 Nferchant/Business Mechanical <br /> e. Iii SL lRIES f FATALITY ;.EVVit'-DATION h.�LE,1,'R--' 'BY: <br /> 0 Yes *No 0 Yes *No 0 Yes *No Responsible Pattv <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> Ia. ON SCENE: b. OTHER ON SCENE: c. OTHER NOTIFIED: <br /> d.ADMIN.AGENCY: San Joaquin County Emergency Services e.SEC.AGENCY: <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> h.NOTIFICATION LIST: <br /> DOG Unit: R%VQCB Unit: 513 <br /> AA/CUPA ❑Ant RESOURCES BD ❑DPR ❑Cal EMA HAZMATUNTT❑SFM ®Co/E-filth <br /> ®DFG-OSPR ❑CALTRANS ❑EB PARKS ❑Cai ETA PLANS= ❑UCSB '❑OTHER <br /> N DTSC ❑CALFIRE ❑EMSA ❑Cal EMA REG ❑USMMS ❑DFG/OSPR/MSU <br /> 0 RWQCB ❑COASTAL COM ❑FEMA ❑OSHA M USCG <br /> 19US EPA ❑CDPH-D.O. ❑FOOD&AG M PARKS&REC ❑Co/WP <br /> ®USFWS ❑DOG MLANDS El PUC Co/Mth <br /> C0NT-ID"E.NTfit 1, <br /> RE URKS: <br /> ��rarn3r�.centerrr)e�gs.catema.ca.gol;i,�I,i;CDOF3lh3?e: 'nEiter+Ji�St_G.n�ii;R9 RRQ@rEPA.GOV:R.CCAEamecfa{aase:g.mii; <br /> I RA <br /> r �;,rn�f_..,. n . S.,- nz�C�;I SC 3_:..RIiT;SC C,tJY5d3iTr ifoC.•l5fit�i_6fnrnnfo(�CBiF.CE.tI+r 3"7SC .Ifi73 <br />