Governor's Office Emergency Services
Hazardous Materials Spill Report

    DATE: 03/25/2023
    TIME: 1125
    RECEIVED BY:
    CONTROL#:
    Cal OES - 23-2196
    NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Solve One
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. Fuel=1 Gal(s)PETROLEUMNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: Reporting Party states a customer had a hole in their fuel tank, and a release occurred while fueling. The fuel went onto concrete, no waterways involved. Employees deployed containment measures and cleaned the spill.
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: 3998 Douglas Blvd (Safeway Fuel Station)
b. CITY:c. COUNTY: d. ZIP:
Roseville
Placer County95661PLACER COUNTY APCD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
03/25/20231045 Merchant/Business 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: Roseville Fire Departmente. SEC. AGENCY: Placer County Environmental Health
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

5B
Cal OES Region:
AA/CUPA, DTSC, RWQCB, US EPA, USFWS
Photo Attachment:
11. Cal OES Reg.
********* Control No: 23-2196 *********

Created by: Warning Center on: 03/25/2023 11:25:58 AM Last Modified by: Warning Center on: 03/25/2023 11:35:28 AM