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SPECIAL OCCURRENCE FORM Central Valley Compost Facility i • This form is used for site compliance with the Solid Waste Facility Permit • The purpose of this Form is simply to provide enough details for a basic understanding of the nature of all site operational special occurrences and to indicate if more detailed files on the occurrence exist . • Completed Forms are to be given to the Environmental Protection Manager for filing in the Special Occurrence Log binder . I • In addition to completion of this Form , all other normally required documents must be complete ( such as injury investigation reports , etc . ) . • Detailed notes and files regarding special occurrences (when applicable ) should be filed separately with a note at the bottom of this form to indicate where the other file is located . I Date : 5 y-123 Time : t \ 25 P� i Reported By (please print) : Jonathan Rocha Position/Title : Supervisor 1) CHECK APPROPRIATE OCCURRENCE (S) j i Fire Accident Receipt/Rejection of Prohibited Hazardous Waste Spill or Release Injury/Illness Disposal of Significant Amounts of Plant Debris ' Flooding Property Damage Unusual and sudden settlement or landslide Explosion Insufficient Personnel Disposal of " Covered Material ,2 High Winds Earthquake Damage Other : ?6 ..ze.Nr X s f C 2) PROVIDE A BRIEF DESCRIPTION OF THE OCCURRENCE BELOW — INCLUDE INDIVIDUALS AND WITNESSES INVOLVED * , COMPANY AFFILIATION, AND OTHER RELEVANT INFORMATION. j *For accident/injury/illness , do not include employee name (s) on this log Par OcV it N �'''w' k4 • }enc. 5• � \ersar �oWe, r . A �- 12 '. 35 P � i � owe� wa.S res-�o �'ec)1 � � �� vt.o 3) PROVIDE ANY FOLLOW-UP ACTIONS (i. e. customer notification , employee training , additional signage, etc .) . l i I i i 4) HAS A SEPARATE FILE WITH DETAILS ON THIS INCIDENT BEEN CREATED ? YES * * NO _X xx LOCATION I i PHOTOS i