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06/03/2008 08:01 FAX 8777958400 INCIDENT REPORT DESK 10003 <br /> WLeIlmerling, Roshell A(WELR) x X Business consultant <br /> I <br /> Reviewers <br /> Reviewer Name Management sponso �Positlon Date Approved <br /> Agency Info <br /> Agency/Other Name: Broadspire Agency Personnel Name: Karla Worrell <br /> Agency Phone Number: 559/271-3825 Agency Report Number: <br /> Agency Call Date/Time. 02/Jun/2008 16:05 <br /> Notifying Employee Name., <br /> Agency Notification Comments: <br /> Agency/Other Name; Mariposa Conty Health Agency Personnel Name, Jeff Paisgaard <br /> Department <br /> Agency Phone Number. 209/381-1087 Agency Report Number <br /> Agency Call DatefTime: 02/Jun/2008 15;50 <br /> Notifying Employee Name: Garrett, Connie D <br /> (CDGA) <br /> Agency Notification Comments., <br /> SpiH-ReleaselProduct Quality Info: <br /> Product Unit of Qnty Released/ Released By Qnty Recovered By <br /> Name: Measure: Contaminated: Air Cont. Land Water Recovered Air Cont. Land Water <br /> Gasoline <br /> RUL Gallons 4 x 4 x <br /> Criventional <br /> 3rd Pa Info <br /> Owner NameAddress Phone Number <br /> Georgia Young <br /> 9812 Weeping Willow DrStockton CA 95209 2099524373 <br /> Description of Damage: <br /> I was putting gas into car&it didn't shut off until 19.5 gallons went into car.When I pulled out hose, gas poured out of car <br /> and kept overflowing down the side of car, all over my legs and shoes. <br /> Was TapRoot@)Methodology Used? <br /> Which Tenets of Operation Were Violated? No Tenets Violated <br /> I.Always operate within design or 6.Aways maintain integrity of dedicated <br /> environmental limits. systems. <br /> 2.Always operate in a safe and controlled 7.AJways comply with all applicable rules and <br /> condition. regulations. <br /> 3JMways ensure safety devices are in place <br /> and functloatq8.Always address abnormal conditions. <br /> . <br /> 4Aways follow safe work practices and 9.Always follow written procedures for high <br /> procedures. risk or unusual situations. <br />