Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 11/16/2024
    TIME: 1018
    RECEIVED BY:
    CONTROL#:
    Cal OES - 24-6439
    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=1 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Per the reporting party, a Chevron customer was pumping gasoline and over filled the tank. The fuel impacted the concrete at the Chevron Service Station. No waterways were impacted. Chevron personnel cleaned the spill and disposed of the waste material in the hazardous materials waste container.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
Stopped, ContainedNoN/ANo
l. MARITIME VESSEL
No		m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: 875 Blossom Hill Road
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
11/16/20240915 Service Station Human Error
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: 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, Co/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 24-6439 *********

Created by: Warning Center on: 11/16/2024 10:18:01 AM Last Modified by: Warning Center on: 11/16/2024 10:34:47 AM