Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 12/02/2023
    TIME: 1616
    RECEIVED BY:
    CONTROL#:
    Cal OES - 23-7420
    NRC - 1385697
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
NRC
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. Unknown Oil =Unknown UnknownPETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per the NRC Report : "Caller reported a discharge of an unknown discharge of unknown oil from an unknown source at the incident location."
Affected Medium: Land / Parking Lot - Gas Station
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Unknown if stopped, Unknown if containedNoN/ANo
l. MARITIME VESSEL
No		m. KNOWN IMPACT
Unknown
3. a. INCIDENT LOCATION: 1550 South State St.
b. CITY:c. COUNTY: d. ZIP:
Ukiah
Mendocino CountyUnknownMENDOCINO COUNTY AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
12/02/202316:00 Service Station Unknown
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoUnknown
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/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 23-7420 *********

Created by: Warning Center on: 12/02/2023 04:16:17 PM Last Modified by: Warning Center on: 12/03/2023 05:46:57 AM