Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 04/29/2019
TIME: 0348
RECEIVED BY: CONTROL#:
Cal OES -
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
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. = NoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION:
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
l. KNOWN IMPACT
3. a. INCIDENT LOCATION:
b. CITY:c. COUNTY: d. ZIP:

4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNo
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
d. ADMIN. AGENCY: e. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
DOG Unit:
RWQCB Unit:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, SFM
Photo Attachment:
********* Control No: *********

Created by: Warning Center on: 04/29/2019 03:48:06 AM Last Modified by: Warning Center on: 04/29/2019 03:48:06 AM