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SPECIAL OCCURRENCE FORM Central Valley Compost Facility y • 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 I binder . • 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 . s Date : 1 • �-� .�'� Time : (o : ''� pM — '1 coca::) Reported By (please print) : Jonathan Rocha Position/Title : Landfill Supervisor 1 1) CHECK APPROPRIATE OCCURRENCE (S) 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' High Winds Earthquake Damage Other : rQ j 2) PROVIDE A BRIEF DESCRIPTION OF THE OCCURRENCE BELOW - INCLUDE INDIVIDUALS AND 3 WITNESSES INVOLVED * , COMPANY AFFILIATION, AND OTHER RELEVANT INFORMATION. 1 *For accident/injury/illness , do not include employee name(s) on this log r3e*.joa04\ 6 '. '� -� -1 '• � � P^'� I 3 ) PROVIDE ANY FOLLOW-UP ACTIONS (i. e . customer notification , employee training , additional signage , etc.) . ` I Sp%"% I ww�zV CHvv,.or%% W wS SG\ .� w %��..J '�2 { lr •vim. {�•�� a wtic� � . on 75,,\, %V4 YL wCAS }4Jv KOC) GAV%64 4) HAS A SEPARATE FILE WITH DETAILS ON THIS INCIDENT BEEN CREATED9 i i YES * * NO X * * LOCATION 1 9 PHOTOS i