Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 12/11/2024
    TIME: 1714
    RECEIVED BY:
    CONTROL#:
    Cal OES - 24-6910
    NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Solve one
1.b. PERSON REPORTING SPILL (If different from above):
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Jackson Energy
2. SUBSTANCE TYPE:
2. a. SUBSTANCE:b.QTY:>=<Amount Measurec. TYPE:d. OTHER:e. PIPELINEf. VESSEL
>= 300 Tons
1. Gasoline=1 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per the reporting party, due to a mechanical failure causing the release of approx 1 gallon of gasoline onto a concrete pad. No waterways have been impacted. The release is stopped and contained. The cleanup material was placed into a 55 gallon drum.
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: 518 Rancho Conejo Blvd
b. CITY:c. COUNTY: d. ZIP:
Thousand Oaks
Ventura County91320VENTURA COUNTY APCD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
12/11/20241600 Merchant/Business Mechanical
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: Ventura County Environmental Healthe. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

4
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, Co/WP, Co/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 24-6910 *********

Created by: Warning Center on: 12/11/2024 05:14:49 PM Last Modified by: Warning Center on: 12/11/2024 05:25:08 PM