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Hazardous Materials Spill Repc 16-5409 Page 1 of 1 <br /> Governor's Office Emergency Services V� <br /> Hazardous Materials Spill Report <br /> DATE: 09/06/2016 RECEIVED BY: CONTROL#: <br /> TIME: 0915 Cal OES- 16-5409 <br /> NRC - <br /> La. PERSON NOTIFYING Cal OES: <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4. Ext: 5. PAG/CELL: <br /> Broadbent <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. b.QTY:>=<Amount Measure c.TYPE: d.OTHER:e. f. VESSEL <br /> SUBSTANCE: PIPELINE >=300 <br /> Tons <br /> 1. Diesel = 5-50 Gal(s) PETROLEUM No No <br /> 2, = No No <br /> 3, = No No <br /> g. Caller states: A leak from an external fuel tank on a private party truck caused the <br /> DESCRIPTION: release. The release was to the ground and a storm drain. <br /> h. CONTAINED: i. WATER j. WATERWAY: k. DRINKING WATER <br /> INVOLVED: IMPACTED <br /> Unknown Yes Storm Drain, Unknown No <br /> where it leads <br /> 1. KNOWN None <br /> IMPACT <br /> 3. a. INCIDENT LOCATION: Flying J - #618 - 1501 Jack Tone Rd. <br /> b. CITY: c. COUNTY: d. ZIP: <br /> Ripon San Joaquin County 95366 SAN JOAQUIN VALLEY <br /> UNIFIED APCD <br /> 4. INCIDENT DESCRIPTION: <br /> a. DATE: b. TIME (Military): c. SITE: d. REPORTED CAUSE <br /> 09/06/2016 0630 Service Station Human Error <br /> e. INJURIES L FATALITY g. EVACUATION h. CLEANUP BY: <br /> No No No Contractor <br /> 6. NOTIFICATION INFORMATION: <br /> a. ON SCENE: b. OTHER ON SCENE: c. OTHER NOTIFIED: <br /> Fire Dept. lvv n <br /> d. ADMIN. AGENCY: San Joaquin County e. SEC.AGENCY: °I'f0'�O' ' g <br /> Environmental Health C M 0- (r24 fj&re?S <br /> f. ADDITIONAL COUNTY: g. ADMIN. AGENCY: 5 4& oa rn,^q Ce n)tq", <br /> h.NOTIFICATION LIST: CAX&j *,i-e.riA'-PJ <br /> DOG Unit: RWQCB Unit: recce <br /> +41 IS- S d+ <br /> 5B 00i. way 40,/7 <br /> AA/CUPA,DFG-OSPR,DTSC,RWQCB,US EPA,USFWS,COASTAL COM,LANDS,PARKS&REC,USCG,Co/WP,Co/Mth,Co/�Hlth��y�1 y I1 prep <br /> 1.ARB: � lt7 F A td-a� -. <br /> ********* Control No: 16-5409 ********* Gi5 a P ,r-e. �_^ <br /> Created by: Warning Center on:09/06/2016 09:15:28 AM Last Modified by: Warning Center on:09/06/2016 09:23:50ou-*'jo- E <br /> AM n0-�' rtceiV k o <br /> J!I,nehs�l.'��} <br /> �OIlYC0 <br />