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02-27-2007 15:17 from-OES HQ SACRAMENTO WIC 918-845-8910 T-140 P.001/001 F-163 <br /> j� GOVERNOR'S OFFICE OF EMERGENCY SERVICES <br /> •� <br /> Hazardous Materials Spill Report,/,,� <br /> DATE: 02/27/2047 RECEIVED BY. CONTROL#: <br /> TIME: 1500 OES- Dacia Young OES- 07-1276 •��0 <br /> OSPR - NRC - �� f <br /> 1.a. PERSON NOTIFYING GOVERNOR'S OES: � <br /> 1. NAME: 2. AGENCY: 3. PHONE#: h.Ext: 5.PAG/CELT.: <br /> Steven Icing Stockton Fire Dept 209 346-6831 <br /> Lb. PERSON REPORTING SPILT.(If different from above): <br /> 1. NAME: 2. AGENCY: 3. PRONE#: 4.Ext: S.PAG/CELL: <br /> 2. SUBSTANCE TYPE; <br /> Z.a.SUBSTANCE, b.QTy.—G Amount !tlrrssure c.TYPE: d.OTHER: <br /> 1.Unknown - Unk Unknown OTHER unknown <br /> 2. <br /> 3. <br /> e.DESCRIPTION: Someone sprayed an unknown substance in the front lobby at an independent living facility <br /> Several people are experiencing nose and throat irritation One person evacuated out of the building nor transported <br /> to medical facility. <br /> L CONTAINED: g.WATER INVOLVED: h.WATERWAY! i. DRINKING WATER IIVIFACTED <br /> 'Y'es No No <br /> 3. a.INCIDENT LOCATION; 1320 North Motuoe <br /> b.CITY: C.COUNTY: d.ZIP: <br /> Stockton San Joaquin County <br /> 4.INCIDENT DESCRIPTION: <br /> a.DATE.02/27/2007 b. TIME (Mvirary):1400 C.SITE: Me�rcbanl/Business <br /> d. INJURIES# e.FATALS#: f.E`VACS#- g CLEANUP BY: <br /> 0 0 1 Unknown <br /> Same as ii1."PE.RSON.N9Y1FYI.N0 OES"j <br /> 5. SUSPECTED RESPONSIBLE PARTY: PHONE#: d,EXT.: <br /> a_NAME: b. AGENCY: C. <br /> Unknown <br /> e.MAIL ADDRESS; f.CITY: g.STATE: h.ZIP, <br /> CA <br /> 6. NOTIFICATION INFORMATION: <br /> b.OTHER ON SCENE: c.OTHER NOTIFIED: <br /> Ia.ON SCENE: <br /> Co Health.,Co OES,Fire Dept.,Police <br /> Dept, <br /> d.ADMIN.AGENCY- San Jauquin County Fmdrgcncy Ser FCS e.SEC.AGENCY; <br /> nOG Univ 12WQCB Unit: 58 <br /> f.NOTIFICATION LIST: _ <br /> ((^�� - f �_uscc � <br /> 9 AArCUPA I I�L'SPWS i.. �JFIS.n Q. ❑1 P00;�&AG 1-.!OSHA <br /> nh'G-OSPR AIR Rk'S011RCP.S DD .-�POG LJ LANDS 7 PARKS&REC 17- wwoi <br /> � 7 i IJ OTITER <br /> =V�LJ7�PTSC rI CALTRANS I�LAB PARKS L_-�OES NAZMA}'UTF17' IJ F'WC <br /> !pJ�RWDCB Ir�eUF EaMSA - URS PLANSUNI7 Ll SPM — <br /> �+y US EPA I J COASTAL CO- MMA -I— 101;2 RRG USMMg - JI <br /> SA-+tiE L�,A�4ur, .r1' �R.ffw. 0-7 <br /> C�Lr-- -Vo C R+.t- ME 07,0.t,tf-- <br />