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01-21-2008 18:48 FrO-OES HO SACRAMENTO W/C 916-645-8810 T-916 P.001 F-184 M <br /> 0 AS GOVERNOR'S OFFICE:OF EMER <br /> I * SERVICES C1 <br /> Hazardous Materials 5 Re <br /> DATE: 07/21/2008 RECEIVED BY: CONTROLM <br /> TIME; 1835 OES- Timothy Britt OES- 08-5337 <br /> OSPR- NRC- <br /> >l.a: PERSON NOTIFYING GOVERNAR'5 OES: • <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/ LL: <br /> Dave Clossen Veeder Root 500-997-7725 2545 <br /> Lb. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#: 4.Ext: S.PAG/CELL: <br /> 2. SUBSTANCE TYPE: <br /> 2.'a.SU13STANCE: b.QTY:>aa A+AaiuAt Measure c.TYPES d.OTHER: <br /> 1. Gasoline - .5 Gai(s) PETROLEUM <br /> 2. <br /> 3. - <br /> e.DESCRIPTION: ILP states that a customer over filled their gas sank causing the release of agpraxi1natC1Y.5 <br /> gallons of gasoline onto the concrete, <br /> i <br /> f.CONTAINED: g.WATER INVOLVED: h.WATERWAY: i.DRINII�,ZG WATER IMPACTED <br /> Yes No <br /> 3. a.INCIDENT LOCATION: 2808 CouuW Club Blvd <br /> b.CITY: c.COUNTY: d.ZIP: <br /> StocLTon San Joaquin County 95204 <br /> 4.INCIDENT DESCRIIPTION: <br /> a.DATE:0712112008 b. TIME (mmary�:1740 a SITE: Service Station <br /> d. INJURIES# e,FATALS#: f.EMACS#: g•CLEArRT BY: <br /> 0 0 0 Unknown <br /> ., " <br /> Same as Si. PSRSaiJ 1dOT1FYlNi"a OESi <br /> SUSPECTED RESPONSIBLE .� <br /> a.NAME: b. AGENCY: c.RESPONSIBLEPARTY' - <br /> PIiONE#: d.EXT.: <br /> Unknown <br /> e.MAIL ADDRESS: [CITY: g.STATE: h.ZIP: <br /> CA <br /> b. NOTIFICATION INFORMATION: <br /> �.ON SCENE: b.OTHER ON SCENE: c.OTHER NO'T'IFIED: <br /> d.ADMIN.AGENCY: San Joaquin County FrncTsency Services e.SEC.AGENCY: <br /> f.NOTIFICATION LIST: DOG Unit: RwQC>3 unit: 513 <br />� A,vCUPA LZ us LJ DHS-0.0. ❑FOOD.Ae ❑0.9— ❑ASC13 <br /> OPC-OSPR ❑.,m Pasoustu's ao L.-1 nor, ❑LANDS ❑PAM&RW El 001 <br /> SC ❑CALTtANS 0 86 FAW ❑OHS H.ZMATUNIT ❑PUC ❑0THH1L <br /> 0•i• <br /> ��• RWQCB ❑CDP L SMSA LJ_`OK-q P!ANs uNrr ❑I SFM <br /> us a?., ❑COMMI-COM I�FSMA ❑OES RHO LJ usMms - <br />