Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 03/03/2021
TIME: 1108
RECEIVED BY: CONTROL#:
Cal OES - 21-1158
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Burrtech
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 =4 Gal(s)CHEMICALNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: RP states that a hose broke on a garbage truck causing the release of the material. No water impacted. A third party conducted the cleanup.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNo
l. KNOWN IMPACT
3. a. INCIDENT LOCATION: 9116 Rangpur Circle
b. CITY:c. COUNTY: d. ZIP:
Riverside
Riverside CountySOUTH COAST AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
03/03/20211015 Road 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: City of Riverside Fire Marshale. SEC. AGENCY: Riverside County Environmental Health
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
i. Cal GEM:
j. RWQCB Unit:

8
k. Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS
Photo Attachment:
11. Cal OES Reg.
********* Control No: 21-1158 *********

Created by: Warning Center on: 03/03/2021 11:08:01 AM Last Modified by: Warning Center on: 03/03/2021 11:12:16 AM