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STATE OF CALIFORNIA <br />DEPARTMENT OF CALIFORNIA HIGHWAY PATROL <br />HAZARDOUS MATERIALS INCIDENT REPORT <br />CHP 407E (Rev. 3-15) OPI 062 Refer to HPM 84.2, Chapter 2 <br />OES CONTROL NUMBER <br />21-3855 <br />COLLISION REPORT <br />[S] Yes NUMBER 9265-2021-10987 Lii No <br /> <br />HAZMAT CASUALTIES NO. EXPOSED/ <br />DECONNED <br />NO. <br />INJURED <br />NO. <br />KILLED <br />CITY <br />Unincorporated <br />JUDICIAL DISTRICT <br />Lodi <br />PHOTOGRAPHS BY <br />Sergeant S. Siria <br />. NONE <br />AGENCY PERSONNEL 0 0 0 COUNTY <br />San Joaquin <br />NCIC <br />9265 <br />HAZMAT PLACARDS DISPLAYED <br />No OTHERS 0 0 0 M Yes <br />INCIDENT DATE (MMIDD/TYYY) <br />07/18/2021 <br />INCIDENT TIME <br />2210 HOURS <br />TIME CALTRANS/COUNTY ROADS NOTIFIED <br />2351 HOU RS <br />TIME O.E.S. NOTIFIED <br />ID913 HOURS <br />STATE HIGHWAY RELATED <br />No j Yes • <br />INCIDENT OCCURRED ON <br />Interstate 5 southbound <br />. AT INTERSECTION <br />WITH <br /> Eight Mile Road North of OR <br />MILEPOST INFORMATION GPS COORDINATES <br />LATn-une 38.079492° LoNGrrunE-121381892° <br />NAME (FIRST, MIDDLE, LAST) <br />Manjeet Singh <br />DRIVERS LICENSE NUMBER <br />D7659645 <br />STATE <br />CA <br />VEH. YEAR <br />2014 <br />MAKE <br />Freightliner <br />LICENSE NUMBER <br />WP71883 <br />STATE <br />CA <br />STREET ADDRESS <br />5373 Calabria Way <br />VEH. YEAR <br />2019 <br />MAKE <br />Utility <br />LICENSE NUMBER <br />4RW5438 <br />STATE <br />CA <br />CITY/STATE/ZIP CODE <br />Sacramento, CA 95835 <br />VEH. YEAR MAKE LICENSE NUMBER STATE <br />HOME PHONE <br />(916) 947-0707 <br />BUSINESS PHONE <br />Unknown <br />CARRIER NAME <br />Doaba Transportation Incorportated RECEIVED <br />HAZMAT IDENTIFICATION SOURCES (CHECK <br />services <br />services <br />ALL THAT APPLY) <br />Control Center <br />Data Sheet <br />papers <br />Response Guidebook <br />material used <br />REGISTERED OWNER SAME AS DRIVER <br />--'' 1 On-site fire services Chemtrec 1.1 <br />Private info source Poison OWNER'S ADDRESS SAME AS DRIVER <br />j.0.I. I I L AL I I I Off-site fire services Safety ENVIRONNIEN On-site non-fire Placards/Signs VEHICLE IDENTIFICATION NUMBER 11 W.P.‘.. Pil NIENT <br />3AKJGLD5XESFY3819 <br />Off-site non-fire Shipping <br />Computer software Emergency <br />VEHICLE TYPE <br />25 31 <br />CA NUMBER <br />466600 <br />DOT NUMBER <br />2598398 <br />Chemist No reference <br />Other <br />CHEMICAUTRADE NAME <br />Engine oil <br />UN <br />NUMBER <br />1270 <br />DOT HAZARD <br />CLASS <br />3 <br />QUANTITY RELEASED <br />(LBS., GAL., ETC.) <br />10 Gallons <br />EXTENT OF RELEASE <br />Outside vehicle <br />PHYSICAL <br />STATE STORED <br />Liquid <br />PHYSICAL STATE <br />RELEASED <br />Liquid <br />CONTAINER TYPE <br />Other (explain in Comments) <br />CONTAINER CAPACITY (LBS., GAL., ETC.) <br />10 Gallons <br />CONTAINER MATERIAL <br />Aluminum/Aluminum alloys <br />LEVEL OF CONTAINER <br />Above ground <br />CHEMICAL/TRADE NAME UN <br />NUMBER <br />DOT HAZARD <br />CLASS <br />QUANTITY RELEASED <br />(LBS., GAL., ETC.) <br />EXTENT OF RELEASE PHYSICAL <br />STATE STORED <br />PHYSICAL STATE <br />RELEASED <br />CONTAINER TYPE CONTAINER CAPACITY (LBS., GAL., ETC.) CONTAINER MATERIAL LEVEL OF CONTAINER <br />PROPERTY USE <br />Agricultural <br />SURROUNDING AREA <br />Agricultural <br />PROPERTY MANAGEMENT <br />Private <br />RELEASE FACTORS <br />Collision/Overturn <br />EQUIPMENT TYPE INVOLVED <br />Other (explain in Comments) <br />HAZMAT CONFIRMED <br />Yes • No <br />CITATION ISSUED OR COMPLAINT TO BE FILED PRIMARY CAUSE OF INCIDENT <br />22107 CVC <br />OTHER HAZARDOUS MATERIALS VIOLATIONS (NON-CAUSAT VE) <br />Yes No • Not determined Violation Yes 4 No <br />DID WEATHER CONTRIBUTE TO CAUSE OR SEVERITY OF INCIDENT? <br />WEATHER <br />Other Code violation <br />Other cause Yes No <br />ELEMENTS (OUTLINE THE FOLLOWING ON A CHP 556. INCLUDE ADDITIONAL INFORMATION AS NECESSARY) <br />Z Sequence of events [g] Evacuation details Z Cleanup actions Z CHP On-scene Personnel (name, rank, ID <br />number, function, exposure, hours) <br />Z Road closures Z Environmental impact Z Actions of other agencies <br />COMPLETE THE FOLLOWING <br />z] Incident Action Plan [g] Site Safety Plan Z Proposition 65 Letters: County Health/County Board of Supervisors <br />DATE AND TIME SCENE DECLARED SAFE BY WHOM (NAME, TITLE AND AGENCY) <br />08/05/2021 1330 HOURS Fred Earnest, Environmental Health Specialist, San Joaqion County Environmental Health Dept. <br />PREPARER'S NAME, RANK, AND ID NUMBER DATE REVIEWERS NAME, RANK, AND ID NUMBER DATE <br />Scott Siria, Sergeant, ID 15813 07/21/2021 It---77t— lb t 4-7-79 g//o/2-0ZI <br />Destroy Previous Editions An Internationally Accredited Agency Chp407E_0515.pdf