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PACIFICEILL.. Fn 0023 0 R51 <br /> NEVADA BELL. loot 019 2WI <br /> Ppcifigt'okmwcon""i" Hazardous Material Incident Report <br /> Date Location Of Release Person Reporting Incident Source Of Discharge li.e., Container, Veh., Facility) <br /> Street Name Source <br /> City State Tel. No. I } <br /> Hazardous Material Quantity Released Date And Time Of Discharge Area And/Or Water Body Endangered <br /> Material Cluantity Date Time <br /> ill Applicablel <br /> Truck No. TNA Or UN Code Placard/Label <br /> Response/Clean-Up Initiated Weather Conditions Extent Of Injuries. If Any <br /> Northern CAL (415) 823-7777 <br /> Emergency Control Center iECCI Southern CAL 818-578.4941 <br /> Nevada 702-786-0090 <br /> Agency IAs Applicable) Tel. No. Date Time Agency Contact Name <br /> National Response Center (NRC) 800-424-8802 <br /> Office Of Emergency Services IOESI CAL 800-852-7550 <br /> California Highway Patrol ICHPI CAL Zenith 12000 <br /> Department Of Conservation And National Resources (DCNR) NEV 702885-4670 <br /> Division Of Emergency Management IDEM) NEV 702-885-5300 <br /> Local Agency lWater Quality Control, Fire Dept., etc ) <br /> Supervisor's <br /> Signature Title Tel. No. I I Date <br /> PaFt 2 — Emergency Conuol Cempf's Copy <br />