Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 09/30/2022
TIME: 1934
RECEIVED BY: CONTROL#:
Cal OES - 22-5778
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
SolvOne
1.b. PERSON REPORTING SPILL (If different from above):
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
SafeWay Station #1724
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: After a customer was done filling up a puddle of gasoline was noticed on the cement pad, no station equipment failure was observed and no waterways were impacted. Safeway Station employees have completed spill mitigation.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNoNoneNo
l. MARITIME VESSEL
No
m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: 3963 Missouri Flat Rd
b. CITY:c. COUNTY: d. ZIP:
Placerville
El Dorado County95667EL DORADO COUNTY APCD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
09/30/20221700 Service Station Unknown
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: El Dorado 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
Photo Attachment:
11. Cal OES Reg.
********* Control No: 22-5778 *********

Created by: Warning Center on: 09/30/2022 07:34:46 PM Last Modified by: Warning Center on: 09/30/2022 08:00:19 PM