Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 11/16/2023
    TIME: 0559
    RECEIVED BY:
    CONTROL#:
    Cal OES - 23-7132
    NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Riverside FD
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. CO 2=Unknown Gal(s)VAPORNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Reporting party states a Circle K there was a leaking hose in the soda machine resulted in the release of an unknown quantity of CO2 into the air. Two employees began experiencing nausea and promptly notified the Fire Department. A hazmat team responded swiftly to the scene and successfully shut down the system to investigate and mitigate the leak. In response to the potential health risk, both Circle K employees have evacuated the area, with one departing via personal vehicle and the other transported by ambulance for further evaluation.
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: 3480 Madison Street
b. CITY:c. COUNTY: d. ZIP:
Riverside
Riverside County92504SOUTH COAST AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
11/16/20230418 Merchant/Business Unknown
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
Yes
Injuries #: 1
NoYes
Evacs #: 2
Unknown
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
Fire Dept.Hazmat, Store ManagersEnvironmental health
d. ADMIN. AGENCY: City of Riverside Fire Marshale. SEC. AGENCY: Riverside County Environmental Health
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

8
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS, AIR RESOURCES BD, Co/Hlth, Co/E-Hlth
Photo Attachment:
11. Cal OES Reg.
********* Control No: 23-7132 *********

Created by: Warning Center on: 11/16/2023 05:59:32 AM Last Modified by: Warning Center on: 11/16/2023 06:23:24 AM