Laserfiche WebLink
H LZ <br /> RUBBER COMPANY, INC . <br /> 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 : Time of Incident : ❑ AAI ❑ PM <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 Ent ergency : ❑ Storage Tank/Drum Leak El Process Release/Spill ❑ Fire ❑ 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 runoff site ? El Yes ❑ No ( If yes, make all required notifications ) <br /> Explain amount and location : <br /> Environment Affected : <br /> ❑ Storage Area(s ) ❑ Parking Areas ❑ Facility Buildings ❑ Entered Sewer( s) <br /> ❑ Entered Storm Drain(s) ❑ Air Release ❑ Roadway ( private ) ❑ Roadway (Public) <br /> ❑ 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 /> Ntedical 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 : Hospital (s ) Transported to : Describe Injuries or Exposure (symptoms ) <br /> S <br />