Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 04/13/2021
TIME: 1924
RECEIVED BY: CONTROL#:
Cal OES - 21-1960
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Private Citizen
1.b. PERSON REPORTING SPILL (If different from above):
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
2. SUBSTANCE TYPE:
2. a. SUBSTANCE:b.QTY:>=<Amount Measurec. TYPE:d. OTHER:e. PIPELINEf. VESSEL
>= 300 Tons
1. Sewage =25 Gal(s)SEWAGENoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Caller states that a manhole cover in front of her house is overflowing down the driving surface and into a storm drain.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Not stoppedYesStorm DrainUnknown
m. KNOWN IMPACT
3. a. INCIDENT LOCATION: 10664 Miguelita Road
b. CITY:c. COUNTY: d. ZIP:
San Jose
Santa Clara County95127BAY AREA AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
04/13/20211915 Road Overflow
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoUnknown
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
d. ADMIN. AGENCY: Santa Clara County Department of Environmental Healthe. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

2
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, DFG-OSPR, DWP-DO, LANDS, PARKS & REC, Co/WP, Co/Hlth, Co/E-Hlth
AA/CUPA; DTSC; RWQCB; US EPA; USFWS; DFG-OSPR; DWP-DO; LANDS; PARKS & REC; Co/WP; Co/Hlth; Co/E-Hlth

Photo Attachment:
11. Cal OES Reg.
********* Control No: 21-1960 *********

Created by: Warning Center on: 04/13/2021 07:24:33 PM Last Modified by: Warning Center on: 04/13/2021 07:31:09 PM