Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 07/24/2021
TIME: 0638
RECEIVED BY: CONTROL#:
Cal OES - 21-3958
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Impact Fine Chemical
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. Mix of Solvents =1 Gal(s)CHEMICALNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: RP states a 5 gallon waste solvent container fell due to unknown reasons spilling approximately 1 gallon of mixed solvent onto concrete. Has been stopped and contained with no waterways impacted.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNo
l. MARITIME VESSEL
m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: HW 50 Hazel Ave
b. CITY:c. COUNTY: d. ZIP:
Rancho Cordova
Sacramento County95741SACRAMENTO METROPOLITAN AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
07/23/20211300 Other
Description for Other : Chemical Facility
Unknown
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoResponsible Party
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
Sac EMD,
d. ADMIN. AGENCY: Sacramento County Environmental Managemente. 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: 21-3958 *********

Created by: Warning Center on: 07/24/2021 06:38:42 AM Last Modified by: Warning Center on: 07/24/2021 06:46:23 AM