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LODI ELECTRIC UTILITY <br /> Oil Spill Report <br /> 1. Date and Time of Spill: _ <br /> Report Completed by: Title : <br /> 3. Location of Spill: <br /> 4. Source of Spill: ❑ Transformer ❑ Regulator ❑ Circuit Brea <br /> ❑ Switch ❑ Hydraulic System ❑ Storage Drum <br /> ❑ Other: <br /> 5. Cause of Spill: ❑ Equipment Leaking ❑ Equipment Failure <br /> ❑ Traffic Accident ❑ Other: <br /> 6. Concentration of PCB's (❑ by field sample) (❑ by records) or ❑ Unknown <br /> 7. Estimated Amount of oil spilled: gallons. <br /> 8. Does the spill affect or threaten the following: * Reporting to NRC, OES and EPA may be required. See <br /> number 9 below. <br /> ❑ River ❑ Creek ❑ Canal ❑ Drainage ditch ❑ Gutter <br /> ❑ Drywell ❑ Sewer ❑ Septic Tank ❑ Pond ❑ Reservoir <br /> ❑ Water Pump ❑ Lake ❑ Lagoon ❑ Grazing lands ❑ Water Supply System <br /> ❑ Vegetable Garden (❑ Swimming Pool *Notification only required for oil with PCBs) <br /> 9. Notifications: Notify Mike Koinzan (209-224-4449) immediately for any spill requiring reporting <br /> to outside agencies.IF YOU AREN'T SURE IF NO TIFICA TIONS ARE NECESSARY, CONTACT209- <br /> 224-4449 OR CHECK WITHSANJOAQUINCOUNTYFOR APPLICABILITY. <br /> ❑ Any spill that threatens public safety,notify San Joaquin County at 209-468-3420 or after <br /> hours,911. Notified by: Date/Time:- <br /> County contact person: <br /> 0 Over 270 gallons unknown PCB concentration, 1 pound pure PCBs, any spill involving AU <br /> category in Section 8 above or over 42 gallons released outside of LEU facilities,call National <br /> Response Center (NRC) (800-424-8802) and OES(1-800-852-7550) <br /> Notified by: Date/Time;. <br /> NRC contact person/reference no.: <br /> OES contact person/reference no.: <br /> ❑ Over 10 pound s pure PCBs or any spill > 50 ppm involving Section 8 above,call EPA Region 9 <br /> (415) 744-2200. if after hours, leave message. <br /> Notified by: Date/Time: <br /> EPA contact/reference no.: <br /> ❑ Property owner: Name/Address/Phone of owner: <br /> Notified by: ❑ Verbal ❑Written Notice Date/Time: ^ <br /> 10. Type of Surfaces Contaminated (asphalt, dirt, grass, pole, auto, etc.): <br /> 11. Weather Conditions (Rain, fog, windy, clear, etc.) <br /> 12. Other agencies involved with spill (police, fire department, media, EPA, County,etc.): <br /> 13. Supervisor in charge of Cleanup: <br /> Name: Title: Telephone: <br /> c:\use rs\mkoinzan\appdata\local\microsoft\windows\te mpor ary internet file s\co ntentoutlo ok\squaivpe\oil spill report and clean up record andcerti ficatio n.doc <br /> 8/12/2014 <br />