Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 11/29/2022
TIME: 1124
RECEIVED BY: CONTROL#:
Cal OES - 22-6998
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Chevron Stations
1.b. PERSON REPORTING SPILL (If different from above):
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Chevron Station #93553
2. SUBSTANCE TYPE:
2. a. SUBSTANCE:b.QTY:>=<Amount Measurec. TYPE:d. OTHER:e. PIPELINEf. VESSEL
>= 300 Tons
1. Gasoline=26 Oz.PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: RP States: When a customer was filling their tank a hole was noticed on their tank spilling gasoline onto the cement pad, no waterways were impacted. The pumps where shut down immediately. Chevron Station employees have completed clean up of the release.
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: 949 Del Presidio Blvd
b. CITY:c. COUNTY: d. ZIP:
San Rafael
Marin County94903BAY AREA AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
11/29/20220900 Service Station Mechanical
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: Marin County Waste Management Officee. SEC. AGENCY: Marin County Communications Center
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

2
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, Co/WP, Co/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 22-6998 *********

Created by: Warning Center on: 11/29/2022 11:24:23 AM Last Modified by: Warning Center on: 11/29/2022 11:32:22 AM