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REPORT OF HAZARDC <br />WASTE INCEDENT <br />to: Office of Emergency Services <br />Hazardous Materials Unit <br />P.O. Box 41907 <br />1-. Facility Operator/Owner's Name and Mailing Address <br />3. US EPA ID No. rani, w'-.VrUVva, UA y0/41-VU4/ <br />MOTOR GUARD CORPORATION <br />CAD982347304 <br />580 CARNEGIE STREET <br />MANTECA, CA 95337 <br />2. Phone Number <br />4. Contact <br />(209) 239-9191 <br />Bill Lee <br />5, Facility Location Name and Mailing Address 7. Contact: <br />MOTOR GUARD CORPORATION Tim Keating <br />580 CARNEGIE STREET <br />MANTECA, CA 95337 <br />6. Phone Number <br />(209) 239-9191 <br />8. Name of Individual Making Report: 9. Phone Number: <br />7 <br />10. Date of Incident: <br />11. Time of Incident: <br />12. Location of Incidi <br />13. Type of Incident: <br />Fire <br />Explosion <br />Spill <br />Un -Planned Release <br />Planned Release <br />Other <br />Describe: <br />14. Hazardous Waste Involved: <br />16. Quantity Recovered: <br />15. Quantity Involved: <br />17. Recovery Method: <br />18. Injuries / Illnesses Resulting from Incident (Describe Injury/Illness and Treatment Given): <br />19. Releases to Environment, Ground Water, Soil, Sewer or Drain (Describe Release and Mitigation Efforts): <br />20. Signature of Reporter: 21. Date Signed: <br />if <br />