Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 11/07/2024
    TIME: 1113
    RECEIVED BY:
    CONTROL#:
    Cal OES - 24-6282
    NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Chevron
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=12 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per reporting party: A customer spilled fuel on the ground while pumping gas due to a hole in the tank. Cleanup is complete.
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: 19180 Bear Valley Road
b. CITY:c. COUNTY: d. ZIP:
Apple Valley
San Bernardino CountyMOJAVE DESERT AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
11/06/20241637 Service Station Human Error
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoGas Station Employee
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
Fire Dept.
d. ADMIN. AGENCY: San Bernardino County Fire Departmente. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

6B
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 24-6282 *********

Created by: Warning Center on: 11/07/2024 11:13:09 AM Last Modified by: Warning Center on: 11/07/2024 11:19:16 AM