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SAN JOAQUIN COUNTY <br /> i <br /> , ENVIRONMENTAL HEALTH DEPARTMENT <br /> (� °,� 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> '. <br /> • Web;www.s ov.or <br /> •. 209 468-3420 • Fax; 209 468-3433J9 9/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: O SHORTTERM#: <br /> PREMISE ADDRESS: // �I r CITY: <br /> DBA: 'CfG/f CROSS ST ET: <br /> PREMISE OWNER: 01-,*a- AJaf PHONE: R <br /> OWNER'S ADDRESS: A'trpori <br /> I CITY: �DG[�I <br /> Cr <br /> FACILITY CONTACT: A" '� C� PHONE: Z 'V <br /> RESPONSIBLE PARTY(RP)DBA: Or ��( /� Ocz Cr e,f •c,--- l4C'`(fo �.m' <br /> 1 I <br /> RP NAME:�►�`"'� S PHONE:f4%%"`& 1 D -1 QO <br /> v 2 S• CITY: S tY o�1 <br /> RP ADDRESS: pp��������,,��yy��,, <br /> RP CONTACT:*NOW- 'e01— �F "- PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) on <br /> �P�V- 2 Q pi s - P-8 d� -r <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Jeffrey Wong SJC EHD (209) 468-0335 J M� <br /> A)kIvarkZ _Q <br /> MATERIAL/CLASSIFICATION(CHEMICAL NVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) <br /> Y ❑N <br /> ❑N 9?)10 r-lAl 41S <br /> ❑Y o <br /> ❑Y o <br /> ❑Y [-i IN <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> It <br /> DATE PROP 65 COMPLETED: ' DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> d.-SHORT-TERM ON TOP NARRATIVE I j4MAP ❑ ANALYTICAL DATA APROP 65/ AR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT I ❑ OTHER AGENCY REPORTS I ❑ ECORD PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />