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EMERGENCY INCIDENT REPORT <br />Company Name: HOLL RUBBER CO. INC. Phone: (209) 368-7171 Address: 1129 S. Sacramento St.• Lodi, CA. 95240 <br />County: San Joaquin Date: <br />Location of Incident: <br />Extent of Emergency: <br />Time of Incident: <br />exact location within the facility) <br />(Explain or describe the situation) <br />❑AM ❑PiVt <br />Type of Incident: ❑Fire ❑Fire/Explosion ❑Chemical Spill MCI emical Release into air ❑Occupational Accident <br />Cause of Ent ergency:❑Storage Tank/Drum Leak El Process Release/Spill ❑Fire ❑Explosion ❑ other (explain below) <br />Explanation. <br />identification of Hazardous iViaterial: Shipping Name: _ <br />Chemical Name: Label Information: <br />Other: <br />UN or NA Number: <br />Trade Name: <br />Physical Description of Hazardous D'taterial: ❑Solid ❑Gas ❑Granule ❑Infectious ❑Liquid ❑Powder ❑Radioactive <br />Has material run off site? ❑Yes ❑No (If yes, make all required notifications) <br />Explain amount and location: <br />Environment Affected: <br />❑Storage Area(s) <br />]Entered Storm Drain(s) <br />]Unimproved Shoulder <br />]Bay/Ocean <br />❑Parking Areas <br />❑Air Release <br />❑Agriculture Land <br />❑Coastal Beach <br />]Threat <br />Health: <br />to environment/wildlife: (Explain) <br />Exposure to Employees: <br />Exposure to Public: <br />Yledical Attention: <br />❑Yes ❑No Number <br />❑Yes <br />❑No Number <br />❑Yes ❑No <br />Evacuation Necessary: ❑Yes ❑No <br />Number of staff evacuated from onsite sources <br />Staff Exposed/Injured: <br />Names: Hospital <br />(s)'fransported to: <br />❑Facility Buildings <br />❑Roadway (private) <br />❑Irrigation Water <br />Employees Injured: <br />Public Injured: <br />❑Entered Sewers) <br />❑Roadway (Public) <br />❑Lake/Stream <br />❑Yes ❑No Number <br />❑Yes ❑No Number <br />Hospitalized: ❑Yes ❑No <br />Number evacuated ti. <br />Ei <br />om onsite sources (if known <br />Describe injuries or Exposure (symptoms) <br />