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APPENDIX A <br /> INCIDENT DETAILS <br /> Date/Time of Report: 12/5/2018 @ 1200 CST ER Manager:Toryus Brantley <br /> Reported by: Cori Responsible Party: Rite Aid#6490 <br /> Company: Rite Aid Contact name: MOD <br /> Call back#: 717-210-8499 Address: 599 E. Valpico Rd. <br /> City/State/Zip: Tracy, CA 95376 <br /> On-site Contact: MOD Phone#: 209-830-0976 <br /> Phone#: 209-830-0976 <br /> Location of Incident: Rite Aid#6490 Latitude: 37.71113 <br /> Address: 599 E. Valpico Rd. Longitude: -121.417135 <br /> City/State/Zip: Tracy, CA 95376 <br /> Billing Information Contact Name <br /> Company Name <br /> Address <br /> City/State/Zip <br /> Phone# <br /> Client PO, ER or other Reference#22773800 <br /> Surface type: ❑Soil ❑Asphalt ❑ Cement ❑Gravel ❑Combination <br /> Impacted Areas: ❑Drain ❑ Parking area ❑ Roadway ❑Dock ❑Trailer <br /> Other: Dumpster <br /> Soil contamination: ®No❑Yes, <br /> Size: <br /> Waterway contamination: No Dyes, Name the body of water or tributary: <br /> Incident Details: ❑ In transit(over the road, rail,etc.) ®Client's facility ❑Client's customer's facility <br /> ❑ Other(specify) ❑Date/Time of Incident: 10/11/2018 @ 1743 CST <br /> Weather: ®Clear ❑Rain ❑Snow ❑ Other Temperature: 75 degrees <br /> Vehicle info ❑Cargo ❑Intermodal Unit ❑Tank car ❑Van ❑Other <br /> Tractor/Unit# Trailer# N/A <br /> Container: Size: (1) 55G Performance package <br /> Container type: markings: <br /> ® DM ❑ DF ❑CF ❑CY ❑TP ❑CM ❑Other <br /> Proper shipping name: Non Hazardous Waste liquid <br /> Actual Volume/Amount Released: (3) 1G latex paint pails RQ <br /> Has an SDS been provided? ®No❑Yes <br /> Have the shipping papers been provided? ® No❑Yes <br /> ❑ N/A <br /> Shipping Document/Tracking Number <br /> Shipper Name/Address <br /> Consignee Name/Address <br /> Has the shipper notified? ® Unknown ❑No ❑ Yes, by: <br /> Self-Performed Cleanup ® No El Yes <br /> Subcontractor Heritage Env. <br /> 4 <br /> Page 7 of 14 <br />