Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 12/07/2023
    TIME: 1305
    RECEIVED BY:
    CONTROL#:
    Cal OES - 23-7516
    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. Coolant=3 Gal(s)CHEMICALNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per the reporting party: A Penkse vehicle had a radiator hose break off causing a release of 3 gallons of coolant onto the asphalt and concrete. A contractor has been contacted to conduct the cleanup.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNoNoNo
l. MARITIME VESSEL
m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: AMPM; 8555 Auburn Folsom Blvd
b. CITY:c. COUNTY: d. ZIP:
Roseville
Placer CountyPLACER COUNTY APCD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
12/07/20231235 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: Roseville Fire Departmente. SEC. AGENCY: Placer County Environmental Health
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/WP, Co/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 23-7516 *********

Created by: Warning Center on: 12/07/2023 01:05:46 PM Last Modified by: Warning Center on: 12/07/2023 01:13:52 PM