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0 I SAN JOAQUIN COUNTY r ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton • CA 95205 (209) 468-3420 • Fax: (209) 468-3433 • Web: www.sjgov.org/ehd EMERGENCY RESPONSE RECORD RESPONSIBLE PARTY (RP) DBA: 6� RP NAME:: RPADDRESS: RP CONTACT: PHONE: CITY: ,,CITY: ,, r44 PHONE: NATURE OF RESPONSE (explosion, spill, leak, Tire, or ananaonea/aumpea material) ►' =i/tc� lu �i d�f-F,n,(.��, � gra �� ut ", of 4"Al TIME RECEIVED: Fob. TIME OF ARRIVAL: TIME OF DEPARTURE: ERSONS AT SCENE LIQUID GAS COMMENTS (GAL) (CU FT) o DATE: 0,3 - SHORTTERM#: PREMISE ADDRESS: Cz�wn c S / 4 . CITY: DBA: �I CROSS STREET: PREMISE OWNER: lmmu4 l ,. �/_. PHONE: OWNER'S ADDRESS: CITY: FACILITY CONTACT: PHONE: RESPONSIBLE PARTY (RP) DBA: 6� RP NAME:: RPADDRESS: RP CONTACT: PHONE: CITY: ,,CITY: ,, r44 PHONE: NATURE OF RESPONSE (explosion, spill, leak, Tire, or ananaonea/aumpea material) ►' =i/tc� lu �i d�f-F,n,(.��, � gra �� ut ", of 4"Al TIME RECEIVED: Fob. TIME OF ARRIVAL: TIME OF DEPARTURE: ERSONS AT SCENE MATFRIAI /CI ASSIFICATION IfNFMIfAI INV NVF"1 11 IDENTIFICATION SPILLED? SOLID (LBS) LIQUID GAS COMMENTS (GAL) (CU FT) o a Mi �� 4Vj'11101101=0 ❑Y ii �I ii 13 �/_. _ MATFRIAI /CI ASSIFICATION IfNFMIfAI INV NVF"1 11 IDENTIFICATION SPILLED? SOLID (LBS) LIQUID GAS COMMENTS (GAL) (CU FT) o a ❑Y 13 o u ❑Y ii ii 13 r j1 o ❑N`�* REFERRALS AND NOTIFICATIONS REFERRED TO (NAME AND ADDRESS) DATE PROP 6S COMPLETED: I) T) U I0 I U ; I DATE LIAR COMPLETED: DATE MAILED IF PERSONS EXPOSED and/or INJURED, "PERSONAL TOXICSUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO ER BINDER COPIES: ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ MAP ❑ ANALYTICAL DATA ❑ PROP 6S / UAR ❑ FILE CREATED ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS ER RECORD Page 1 10/03/12