Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 10/04/2022
TIME: 1208
RECEIVED BY: CONTROL#:
Cal OES - 22-5844
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
US Foods
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. Ammonia=5 Gal(s)CHEMICALNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Reporting Party states the business is repairing their roof, and the valve group got moved during renovation. The valve group began leaking ammonia (liquid form) for 15 to 20 minutes before the leak could be stopped. On-site contractor provided clean-up.
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: 15155 Northam Street
b. CITY:c. COUNTY: d. ZIP:
La Mirada
Los Angeles County90638SOUTH COAST AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
10/04/20221100 Merchant/Business Human Error
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoContractor
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
d. ADMIN. AGENCY: LACoFD Health Haz-Mate. SEC. AGENCY:
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

4
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS
Photo Attachment:
11. Cal OES Reg.
********* Control No: 22-5844 *********

Created by: Warning Center on: 10/04/2022 12:08:34 PM Last Modified by: Warning Center on: 10/04/2022 12:18:23 PM