Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 11/28/2023
    TIME: 1043
    RECEIVED BY:
    CONTROL#:
    Cal OES - 23-7315
    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:
2. SUBSTANCE TYPE:
2. a. SUBSTANCE:b.QTY:>=<Amount Measurec. TYPE:d. OTHER:e. PIPELINEf. VESSEL
>= 300 Tons
1. Unleaded Gasoline=2 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per reporting party there was a release of 2 gallons of unleaded gasoline onto the concrete fuel pad due to human error. The release is stopped and contained. No waterways were impacted. Safeway personnel conducted the clean up.
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: 5740 Cottle Rd, Safeway #2900
b. CITY:c. COUNTY: d. ZIP:
San Jose
Santa Clara County95123BAY AREA AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
11/28/20230523 Merchant/Business Human Error
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoSafeway Personnel
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
d. ADMIN. AGENCY: Santa Clara County Department of Environmental Healthe. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

2
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS
Photo Attachment:
11. Cal OES Reg.
********* Control No: 23-7315 *********

Created by: Warning Center on: 11/28/2023 10:43:05 AM Last Modified by: Warning Center on: 11/28/2023 10:53:41 AM