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LZ <br /> RUBBER COMPANY, INC . <br /> EMERGENCY INCIDENT REPORT <br /> Company Name: HOLZ RUBBER CO . INC. Phone: (209 ) 368-7171 Address : 1129 S . Sacramento St. , Lodi , CA . 95240 <br /> County : San Joaquin Date : Time of Incident: ❑ AM ❑ PNf <br /> Location of Incident : <br /> ( Explain exact location within the facility) <br /> Extent of Emergency : <br /> ( Explain or describe the situation ) <br /> Type of Incident: ❑ Fire ❑ Fire/Explosion ❑ Chemical Spill ❑ Chemical Release into air ❑ Occupational Accident <br /> Cause of Emergeney : ❑ Storage Tank/Drum Leak El Process Release/Spill ❑ Fiice ❑ Explosion ❑ other (explain below) <br /> Explanation : <br /> Identification of Hazardous Material : Shipping Name : UN or NA Number : <br /> Chemical Name: Label Information : Trade Name : <br /> Other: <br /> Physical Description of Hazardous Material : ❑ 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 /> El Storage Area(s) ❑ Parking Areas ❑ Facility Buildings ❑ Entered Sewer(s) <br /> ❑ Entered Stonn Drain (s ) ❑ Air Release El Roadway (private) ❑ Roadway ( Public) <br /> El Unimproved Shoulder ❑ Agriculture Land ❑ Irrigation Water ❑ Lake/Stream <br /> ❑ Bay/Ocean ❑ Coastal Beach <br /> ❑Threat to environment/wildlife: ( Explain ) <br /> Health : <br /> Exposure to Employees : ❑ Yes ❑ No Number . Employees Injured : ❑ Yes ❑ No Number <br /> Exposure to Public : ❑ Yes ❑ No Number . Public Injured: ❑ Yes ❑ No Number <br /> Medical Attention : ❑ Yes ❑ No Hospitalized : ❑ Yes ❑ No <br /> Evacuation Necessary : ❑ Yes ❑ No <br /> Number of staff evacuated from onsite sources Number evacuated from onsite sources ( if known ) <br /> Staff Exposed/Injured : <br /> Names: Flospital(s) Transported to : Describe Injuries or Exposure (symptoms) <br /> 8 <br />