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REF#: <br /> INCIDENT INVESTIGATION REPORT FORM <br /> CLOSE-OUT <br /> Investigation Review Sessions: <br /> Date of Review Personnel in Attendance Subject of Meeting <br /> Session <br /> 5/27/21 Efrain Adame Identify Cause of leak <br /> 5/27/21 Jimmee Kim <br /> Status of Recommendations: <br /> Recommendation Status/Comments Date <br /> No. <br /> N/A <br /> Other: <br /> Required? Task Date <br /> Yes No Completed <br /> O0 Initial contact appropriate regulatory agencies 5/26/21 <br /> Q r__% <br /> Follow-up with appropriate regulatory agencies 5/27/21 <br /> OQ Review Incident Investigation Report Form with affected employees(or contractors, 5/26/21 <br /> if applicable) <br /> ® @ Management of Change initiated N/A <br /> O (F) Update RMP submittal to EPA* N/A <br /> *NOTE:Per EPA CFR Part 68.190 "The owner or operator shall include in the Five Year Accident History all <br /> accidental releases from coveredprocesses that resulted in death,injuries,or significantproperty damage on <br /> site or known offsite deaths, injuries, evacuations, sheltering in place,property damage, or environmental <br /> damage." <br /> Clarification: EPA defines "significant"property damage as `Any on-site property damage that exceeds <br /> $50,000.00".This will trigger the need to provide an update to your EPA Risk Management Plan within six(6) <br /> months of the incident. <br /> It is recommended that the incident investigation be considered complete and that the Tea7bbef lly disbanded. <br /> Investigation Team A ve <br /> Leader: y: <br /> V4r.- g Z4 <br /> Ja c Date Signature Date <br /> Eai Ad a m e AGM Ramona Lozada GM <br /> Naille Title Name Title <br /> Copy Distribution: <br /> ❑ Depot Manager ❑ Facilities Manager ❑Depot Operations Mgr ❑Other: <br /> Page 5 of 5 II FORM(7/2018) <br />