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Oct 12 09 10: 43a San aluin C 2099539 p. 13 <br /> CALIFORNIA HAZARDOUS MATERIALS INCIDENT REPORT SYSTEM <br /> A AGENCY NAME AGENCY ID NO, rDENT NO, JAG TEL NO. STATE DES CONTROL NO. <br /> San Joaquin OES 39807 XSJ-01246 (209)953-6200 NIA <br /> NCIDENT DATE TIME NOTIFIED E COMFIWED DATE COMPLETED <br /> B 2J I5120i1l 141 0 1530 If DIFFERENT FROM <br /> INCIDENT DATE <br /> INCIDENT ADDRFSS/LOCATION CITY/COMMUNITY COUNTY 21P <br /> C Gawne Rd I mile east of Mobley Rd Unincorporated San Joaquin <br /> WEATHER ITEMP I PBQPERTY USE ISURROUNWNC4 <br /> D I CLEAR 962 CountylCity Road 6.50 Agricultural County <br /> RELEASE FACTORS IWEOF EQUWENTINYOI, <br /> E 31 Abandoned 99 No Equip Involved 98 No Mobile Property involved <br /> i ACTIONS TAKEN <br /> F 41—Remove hazard(Neutraiize);42 ID1Analysis of hazmat <br /> CHF-MICAL OR'TRADE NAMt T ID NO. IIA�.1►RI7 CLASSr <br /> NO. <br /> Latex faint <br /> HYSICAL STATE PHYSICMI STATS QUANTITYRELEASED JENVIRONMENTAL CONTAMINATION EX7TWTOF <br /> GRED RELEASED RELEASE <br /> 2 Liquid None None 8 NO RELEASE <br /> 03�'TAINERDESCRIPTION NTAINERTYPE VELOFCOINTAINER CONTAINF.RMATERIAL WAINER CAPACITY <br /> 2,Portable 13 Can or Bottle 11 Ground Level 2 Aluminum&Alloys 1 gallon <br /> G CHEMICAL OR TRADE NAME ID NO. HAZARD CLASS CAS NO. <br /> N.j <br /> PHYSICAL STATE IPRYSICALSTATE QUA_vl'ITY RELEASED ENVIRONMENTAL CONTAMINATION 1EXTENTOF <br /> BEI} RELEASED LEASE <br /> ONTAiNER DESCRI7rION ONTAINER TYPE LEVEL OF CONTAINER CONTAINER MAI ER]AL NTAINER CAPACLTY <br /> MORE THAN 2 SUBSTANCES INVOLVED? ❑YE5 ®NO <br /> ADDITIONAL INFORMATION <br /> H <br /> 1.A B C D 2, A B C D 3. A 8 C D 4, A B C-D S. A B C D 6. A B C D <br /> SPECIAL <br /> STUDIES LOCAL STATE <br /> USE -- — - - - — ——— _. —"AZMAT IDENTIFICATION SOURCES T CASUALTIES <br /> PERSONNEL REFERENCE MATERIAL #OF //OF OF <br /> 40 On-Site Non-Fine 98 No Reference COVTAMINAT> D INJURIES FATALITIES <br /> RESPONDING 0 0 0 <br /> Services Material Used AGENCY PERSONNEL <br /> OTHERS D 0 <br /> EHICLE MAKEEYF_P.R 6HICLT LICENSE No WA-1V IV EFnoI:iD NO.(vLN) CAIDOT/PUCIICC NO. COMPANY NAME <br /> K N/A <br /> L EPORTING OFFICER NAMFAD NO.(PRINT OR TYPE) DATE C0141NiENTS ATTACHED <br /> M Parissi,OES8 211612001 NO <br />