Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 11/29/2021
TIME: 1755
RECEIVED BY: CONTROL#:
Cal OES - 21-6782
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Clear Lake Oaks County District
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<500 Gal(s)SEWAGENoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: RP states a 6 inch sewer line had a blockage due to debris. This caused material to come out of a manhole at a slow rate. Release has been stopped and contained with no waterways impacted. Line has been cleared and released material has been cleaned.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNo
l. MARITIME VESSEL
m. KNOWN IMPACT
Road Closure
3. a. INCIDENT LOCATION: Intersection of Beryl Way and State HWY 20
b. CITY:c. COUNTY: d. ZIP:
Clearlake Oaks
Lake County95423LAKE COUNTY AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
11/29/20211043 Road Blockage
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoReporting Party
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
Cal Trans
d. ADMIN. AGENCY: Lake County Health Departmente. 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: 21-6782 *********

Created by: Warning Center on: 11/29/2021 05:55:32 PM Last Modified by: Warning Center on: 11/29/2021 06:18:54 PM