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C06=0 REF#: COSTCO WHOLESALE DEPOT 172 PSM AMMONIA—INCIDENT INVESTIGATION REPORT Facility Information: Facility Name: Tracy Wet Depot Facility Address: 25501 Gateway Blvd Name of Person Completing form: Jimmee Kim Normal Ammonia Inventory: 32,148 lbs Incident Type(Check any that apply): Date&Time of Incident:5/26/21- 1135 am Duration: 2 min Date&Time of Start of Investigation: 5/26/21, 12 p ✓❑Near-Miss DLiquid Spill Q Vapor Release Fire/Explosion Other: Primary Source of Incident(Check One): E3 Oil Drain Valve ❑Pump ❑Pressure Relief Valve ❑Compressor ❑Pressure Vessel []Automatic Control Valve ❑Condenser/Desuperheater []Piping ❑Charging Connection/Source ❑Evaporator []Manual Valve ElOther Hot Gas Strainer Cap Cause(s)Contributing to Release(Check any that apply): ❑Human Factors []Equipment Defect/Malfunction []Controls Failure ❑Design Shortcoming ❑Improper Installation []Process Upset ❑Misapplied Equipment []Mechanical Damage ❑Other Emergency []Power Failure []Hydrostatic Expansion ❑System Change ❑Corrosion []Hydraulic Shock []Maintenance Activity ❑Inadequate Maintenance ❑Inadequate Administrative Controls [I Inadequate Labeling ❑Earthquake DOther: Temperature fluctuation Types of Changes Recommended to Prevent Recurrence(Check any that apply): ADMINISTRATIVE CHANGES ENGINEERING CHANGES ❑ Operating Procedures ❑ Design ❑ Additional Training ❑ Equipment ❑ Emergency Response Procedures ❑ Piping ❑ Safe Work Practices ❑ Safety Equipment ❑ Labeling/Identification ❑ Mechanical Protection/Access ❑ Maintenance Procedures ❑ Controls ❑ Management of Change Procedures None 0 None Results of Incident(Provide Requested Information): Total Quantity of Ammonia Released: Less than 1 Ib Number of Serious Injuries: 0 Estimate of Property/Product Damages: $0 Number of Fatalities: 0 Date of resolution of all recommendations: N/A Date findings were reviewed by affected personnel: N/A Pagel of 5 II FORM(7/2018)