Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 12/08/2023
    TIME: 1351
    RECEIVED BY:
    CONTROL#:
    Cal OES - 23-7532
    NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
ERTS
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. Diesel Fuel =6 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per Reporting Party : There was a hole in a customers vehicle fuel tank that caused the release onto concrete during fueling. The material puddled on the concrete surrounding the pump area. The material did not enter any storm drains or waterways, a contractor is in route for clean up.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, Not containedNoN/ANo
l. MARITIME VESSEL
No
m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: 1105 Airport Park Blvd; Quick Stop - store # 550140
b. CITY:c. COUNTY: d. ZIP:
Ukiah
Mendocino County95482MENDOCINO COUNTY AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
12/08/20231305 Service Station Mechanical
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoContractor
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
d. ADMIN. AGENCY: Mendocino County Health Departmente. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

1
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: 23-7532 *********

Created by: Warning Center on: 12/08/2023 01:51:17 PM Last Modified by: Warning Center on: 12/08/2023 01:58:43 PM