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10-14-2008 08:50 From-OES HQ SACRAVENTO W/C 916-845-8910 T-306 P F-931 <br /> L) L' �S, GOVERNOR'S OFFICE OF EM G <br /> SERVICES <br /> hlazardous Materials Spill Repo <br /> DATE: 10/14/2009 RECEIVED BY: CONTROL#: <br /> TIME. 0832 OES- Bob Mcrae OES- 08-7411 . <br /> OSPR- NRC - , <br /> .t.a. PERSON NOTIFYING GOVERNOR'S OES: <br /> 1. NAME: 2, AGENCY: 3. PHONE#: 4.Ext: S. PAG/CELL: <br /> Chris Fisber Exel Insurance: 610-968-9460 <br /> 1.b. PERSON REPORTING SPILL(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PHONE#; 4. Fxt: S.PAG/CELT.: <br /> 2. SUBSTANCE TYPE: <br /> I` <br /> 2.a.SUBSTANCE: b.QTY:�=� an,ousr Mer+sr�ie r.TYPE- d.OTHER: <br /> 1 DicsGl i00 �aal(s) PF-TROLEUM <br /> 3. _ <br /> e:DESCRIPTION: A tank was overfilled during off-load. <br /> t. CONTAINED: g.WATER INVOLVED: 11.WATERWAY: i.DRINKING WATER IMPACTED <br /> Yes No <br /> No <br /> 3. 1.INCIDENT LOCATION; Couhs Trucking, 1500 Ma,&ugq Dr, <br /> b,CITY: e.COUNTY: d. ZIP: <br /> Lathrop San Joaquin County <br /> 4. INCIDENT DESCRIPTION: <br /> u.DATE. 10/14/2008 b. TIME (Military):0200 c.SITE: Other <br /> d. IN.IUR7ES# e,FATALS#; f.E'VACS#: g.CLEANUP BY: <br /> p 0 0 Contractor <br /> Same as#7"PERSON NOTIFYINC.7 OF-S" <br /> 5. SUSPECTED RESPONSIBLE PARTY: <br /> a.NAME: b. AGENCY: c.PHONE#: d.EXT.: <br /> Kenan Advantage Group 330-409-1077 <br /> e.MAIL ADDRESS: f.CITY: g.STATE h. ZIP: <br /> 6. NOTIFTCATION INFORMATION: <br /> .�. ON SCENE; b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> d.ADMIN.AGENCY: San)naquin Cououy klnurgency Scrvices e.SGC.AGENCY: <br /> f. NO'T'IFICATION LIST; DOC Univ RWQCB Unit: sn <br /> IM1,1 ANC�Pn ---• I.�l usrurs� CpPFE•a•t?• I.J Ft.MA , L_I ors s;co__... L.1 UsMM� ....._._— I,_!OTHEF ._...__I <br /> DPG-OSPR !. J AM RF-101P CBS BD WIGI I P400 SAC O511A ��u&CG <br /> I <br /> I LANe$ ' L...)PARKS d Iti=O l-.I Co1WP'•;>7T84 1.]C:n�TRAMS F1 DPP. II <br /> Iew003 CDF In.1 er rAK1cs F 102SµAZMATLfNI"r !r�I <br /> CoIP•Hllh <br /> 1� US GPA COA�1'AL COM l__I INSA I�OES PLANS UW I I SPM —� <br /> i <br /> I <br />