Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 12/03/2024
    TIME: 1747
    RECEIVED BY:
    CONTROL#:
    Cal OES - 24-6743
    NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Chevron Station Inc.
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. Gasoline=2 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per the reporting party, the listed Chevron Station experienced a fuel spill when a customer drove away with the fuel nozzle still inserted in the vehicle. The spill impacted the concrete pad at the Chevron Station. No waterways were affected by this spill. Chevron personnel cleaned the spill..
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNoN/ANo
l. MARITIME VESSEL
No		m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: 945 Twelve Bridge Drive
b. CITY:c. COUNTY: d. ZIP:
Lincoln
Placer County95648PLACER COUNTY APCD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
12/02/20241600 Service Station Human Error
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoReporting Party
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
d. ADMIN. AGENCY: Placer County Environmental Healthe. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

5B
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, Co/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 24-6743 *********

Created by: Warning Center on: 12/03/2024 05:47:19 PM Last Modified by: Warning Center on: 12/03/2024 06:11:26 PM