Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 11/29/2021
TIME: 0936
RECEIVED BY: CONTROL#:
Cal OES - 21-6767
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Child Care Resource Center
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. Gasoline=2 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: RP states that approx. 2 gallons of gasoline were released onto the parking lot due to a hole in the fuel tank, the release has been stopped and contained, RP personnel conducted cleanup.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNoNo
l. MARITIME VESSEL
No
m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: 2824 W St.
b. CITY:c. COUNTY: d. ZIP:
San Bernardino
San Bernardino CountySOUTH COAST AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
11/29/20210800 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: San Bernardino County Fire Departmente. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

8
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, Co/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 21-6767 *********

Created by: Warning Center on: 11/29/2021 09:36:30 AM Last Modified by: Warning Center on: 11/29/2021 09:44:18 AM