Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 11/27/2023
    TIME: 1204
    RECEIVED BY:
    CONTROL#:
    Cal OES - 23-7293
    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. Diesel=5-9 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per the reporting party: A release of diesel fuel occurred due to there being a hole in a customer's gas tank. The customer attempted to put fuel into the vehicle causing diesel to spill onto the concrete.Chevron personnel have conducted cleanup and placed recovered diesel into waste drums.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNoNoNo
l. MARITIME VESSEL
m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: 4300 Madison Ave
b. CITY:c. COUNTY: d. ZIP:
Sacramento
Sacramento County95842SACRAMENTO METROPOLITAN AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
11/27/20231030 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: Sacramento City Fire Departmente. SEC. AGENCY: Sacramento County Environmental Management
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

5B
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: 23-7293 *********

Created by: Warning Center on: 11/27/2023 12:04:21 PM Last Modified by: Warning Center on: 11/27/2023 12:22:04 PM