Governor's Office Emergency Services
Hazardous Materials Spill Report

DATE: 05/24/2022
TIME: 0715		RECEIVED BY: CONTROL#:
Cal OES - 22-2952
NRC -
1.a. PERSON NOTIFYING Cal OES:
1. NAME:2. AGENCY:3. PHONE#:4. Ext:5. PAG/CELL:
Hazmat 1
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. Chloroform=1 Gal(s)CHEMICALNoNo
2. = NoNo
3. = NoNo
g. DESCRIPTION: RP states: A fork-lift punctured a 5 gallon pale resulting in the release of the material. The release is stopped and contained. No waterways were impacted. Clean up was completed by Onsite personnel.
h. STOPPAGE/CONTAINMENT:i. WATER INVOLVED: j. WATERWAY:k. DRINKING WATER IMPACTED
StoppedNoNo
l. MARITIME VESSEL
No		m. KNOWN IMPACT
None
3. a. INCIDENT LOCATION: 11937 Regent View Avenue
b. CITY:c. COUNTY: d. ZIP:
Downey
Los Angeles County90241SOUTH COAST AQMD
4. INCIDENT DESCRIPTION:
a. DATE:b. TIME (Military):c. SITE:d. REPORTED CAUSE
05/24/20220550 Other
Description for Other : Truck Dock		Human Error
e. INJURIESf. FATALITY g. EVACUATIONh. CLEANUP BY:
NoNoNoOn site personnel
6. NOTIFICATION INFORMATION:
a. ON SCENE:b. OTHER ON SCENE: c. OTHER NOTIFIED:
d. ADMIN. AGENCY: Downey Fire Departmente. SEC. AGENCY: LACoFD Health Haz-Mat
f. ADDITIONAL COUNTY: g. ADMIN. AGENCY:
h. NOTIFICATION LIST:
Cal GEM:
RWQCB Unit:

4
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: 22-2952 *********

Created by: Warning Center on: 05/24/2022 07:15:31 AM Last Modified by: Warning Center on: 05/24/2022 07:22:33 AM