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From:CALIFORHIA STATE WARNING CNTQ 19168458910 06/09/2 16:50 #817 P.001/001 <br /> California Emergency Management Agency <br /> Hazardous Materials Spill Report <br /> DATE: 06/09/2011 RECEIVED BY: CONTROL#: D <br /> TIME: 1646 Cal EMA- Sibyl Clark Cal EMA- 11-3470 <br /> OSPR- NRC- I <br /> <br /> <br /> <br /> I.b. PERSON REPORTING SPILL(If different from above): %R1 <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.GG <br /> 2. SUBSTANCE TYPE: <br /> 2.a.SUBSTANCE: b.QTY: Amount Measure e.TYPE: d.OTHER: e. VESSEL <br /> >=< >=300 Tons <br /> 1. Ethanol = 2 Gal(s) CHElvIICAL O Yes 0 No <br /> 2. = O Yes 0 No <br /> 3. = O Yes 0 No <br /> e.DESCRIPTION: During maintenance activities some of the material was bled into a bucket with 2 or less <br /> gallons spilling into a secondary containment area. <br /> L CONTAINED: g.WATER It.WATERWAY: i.DRINMNG WATER IMPACTED <br /> INVOLVED: <br /> Yes No <br /> j.KNOWN IMPACT <br /> 3. a.INCIDENT LOCATION: 3028 Navy Dr. <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Stockton San Joaquin County 95206 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (Military): C.SITE: d. CAUSE <br /> 06/08/2011 0900 Merchant/Business Mechanical <br /> e. INJURIES L FAT.ld:,ITY g.EV:ACI IATI 0N it.CLEANUP BY: <br /> O Yes *No O Yes *No O Yes *No Responsible Party <br /> <br /> <br /> <br /> <br /> <br /> <br /> Ia.ON SCENE: b.OTHER ON SCENE: c. OTHER NOTIFIED: <br /> San Joaquin Co.Env. Health <br /> d.ADMIN.AGENCY: San 3oaquin County Fmergency Services e.SEC.AGENCY: <br /> f. ADDITIONAL COUNTY: g.ADMIN.AGENCY: <br /> It.NOTIFICATION LIST: <br /> DOG Unit: RWQCB Unit: 5B <br /> NA CUPA ❑AIR RESOURCES BD ❑DPR ❑Cel EMA}GZMATUNrr❑SFM ❑of <br /> N DFO-OSPR ❑CALTRANS ❑m PARKS ❑Cal EMAPI.AHS= ❑USl9.S3 ❑DFO/OSPR/MSU <br /> N DISC ❑CDF ❑©.SSA ❑Cd EMAREO ❑USco <br /> N RWQCB ❑CoAS COM ❑FEMA ❑OSHA ❑c./ <br /> NUS EPA ❑CDPH-D.O. ❑FOOD&AO ❑PARKS&REC ❑camth <br /> N USMS ❑D00 ❑LMDS ❑PUC ❑Co/E-Hn <br /> CONT ENTIAL <br /> REMARKS: <br /> <br /> <br /> <br /> <br /> <br />