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SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N; { <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax:(209) 468-3433 • Web;www.sigov.org/ehd <br /> 9C%FORS\ <br /> EMERGENCY RESPONSE RECORD <br /> DATE: I SHORTTERM#:00003?C'0 <br /> PREMISE ADDRE S: CITY: <br /> DBA: " Oy- c,,.-., L CROSS STREET: <br /> PREMISE OWNER: ) r T' PHONE: L <br /> OWNER'SADDRESS: 22-:0 w �I/-�4SLL/� 'Ia.�'S� CITY: �p.7Ya'� -^�. <br /> FACILITY CONTACT: LII� I 5;e,'4 <br /> " AogC PHONE: !U— C� <br /> RESPONSIBLE PARTY(RP(DBA: V�_&c.,— rjorc <br /> RP NAME: I 1 /-1 — S $1'1" a Cr PHONE: 1�7}�. <br /> RP ADDRESS: C. CITY: 1-1 (45 <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> �,�LrcCRi. PosrJ�c6Jla- (2o L 0 - <br /> TIME RECEIVED: TIME OFARRIVAL: TIME OF DEPARTURE: ^' IS <br /> PERSONS AT SCEN E <br /> NAME AGENCY PHONE TOA TOD <br /> c 1 SJC EHD <br /> 4, / b t <br /> MATERIAL/CLASSIFICATION(aemim, ml <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LSs)) (GAL) ICU FT)) <br /> LJAY DN 5 <br /> DY ON <br /> DY ON <br /> DY DN <br /> DY ON <br /> DY ON <br /> REFERRALS AND NOTIFICATIONS u <br /> LA <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 6S COMPLETED: Yi 'J( 3 DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COM PLEFED7 D YES D NO <br /> ER BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE MAP 0 ANALYTICAL DATA EdAROP 65/UAR D FILE CREATED <br /> 0 MANIFEST 0 REFERRALS 0 CLEAN UP REPORT 0 OTHER AGENCY REPORTS D EXPOSURE RECORD HOTOS <br /> ER RECORD Page 1 10/03/12 <br />