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From:CALIFORHIA STATE WARNING rNTR 19168458910 03/10/2012 09;22 #213 P.001/001 <br /> California Emergency Management Ag <br /> Hazardous Materials Spill Rerori 2` �^ <br /> DATE: 03/10/2012 RECEIVED BY: CONTROL#: <br /> TIME: 0904 Cal EMA- Ruben Rodriguez Cal EMA- 12-1372 <br /> OSPR- NRC- <br /> La. PERSON NOTIFYING Cal EMA: � <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: 5.PAG/CEL <br /> F3roadbent and Associates <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. Gasoline - 10 Gal(s) PETROLEUM O Yes •No O Yes 0 No <br /> 2. = O Yes •No O Yes • No <br /> 3. = O Yes f No O Yes * No <br /> g. DES�:RII''1 ION: 'While replacing a spare fire on a vehicle,the gas tank Was inadvertently punctured by the <br /> jack being used. <br /> h.CONTAINED: i.WATER j.WATERWAY: k.DRINKING WATER IMPACTED <br /> INVOLVED: <br /> Yes No <br /> 1.KNOWN IMPACT <br /> 3. a.INCIDENT LOCATION: 'Pilot Travel Center!i 618, 1501 North.Jack Tone Road <br /> b.CITY: c.COUNTY: d.ZIP: <br /> Ripon San.foaquin County 95366 <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE: b. TIME (Military): C.SITE: d. CAUSE <br /> 03/09/2012 2000 Service Station Human Error <br /> e, INJURIES f FXFAJ:J:TY ty.:FI:VAt t iAIJON h.CLEA_NL'P:l;`'s': <br /> O Yes *No O Yes *No O Yes *No Site Personnel <br /> <br /> <br /> <br /> <br /> <br /> 6. NOTIFICATION INFORMATION: <br /> Ia.ON SCENE: b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> Fire Dept.,Police Dept. <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: RWQCB Unit: 5B <br /> N AA/CUPA ❑AIR RESOURCES BD ❑DPR ❑Cal EMAHAZMATUNrr❑SFM ❑Co/E-Hlth <br /> N DFG-OSPR ❑CALTRANS ❑EB PARKS ❑Cal EMAPLANS UNrr ❑UCSB ❑OTHER <br /> N DISC ❑CALFIRE ❑EMSA ❑Cal EMA REG ❑USMMS ❑DFG/OSPR/MSU <br /> N RWQCB ❑COASTAL COM ❑FEMA ❑OSHA ❑USCG <br /> N US EPA ❑CDPH-D.O. ❑FOOD&AG ❑PARKS&REC ❑Co/WP <br /> N USFWS ❑DOG ❑LANDS ❑PUC ❑Co/Hlth <br /> CONFIDENTIAL. <br /> REMARKS: <br /> : <br /> Warrirg.center f tl1TS.Caiama.Ca.gOP:.�_RKf:f•F.Pe�.CifTL:I)'FSi�.i!;R!,i�maii.oD2l2 <br /> fWSc,eataspi11r"j3t!Ays.gov;mwelton,Avaterboards.ca.gov <br />