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P°"I" • SAN JOAQ UIN COUNTY <br /> �o.�•�.coG � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax.(209)468-3433 • Web.www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: lb-A SHORTTERM#:C O <br /> PREMISdc <br /> ADDRES ��� GL1,tn. CITY:[.(+L <br /> DBA: It� �t CROSS STREET: G <br /> PREMISEOWNER: PH EV <br /> OWNER'S ADDRESS: P70 . g(/ CITY <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: %A PHONE: S ^� <br /> RP ADDRESS: S `b CITY: � 'l <br /> RP S CONTACT: A PHONE: A <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> 10-2,0 Az'aots 41 <br /> TIME RECEIVED: :�S AA- ITIME OF ARRIVAL: 10 TIME OF DEPARTURE: Q .�- <br /> PERSONS AT SCENE <br /> i <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD <br /> 7k <br /> MATERIAL/CLASSIFICATION(CHEMIC LINVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GASCOMMENTS <br /> (LBS) (GAL) (W FT) <br /> �- Y ❑N rA 41 <br /> ❑Y ❑N <br /> o ❑N <br /> ❑Y o <br /> o ❑N <br /> ❑Y n <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: 40 1 DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER INDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE MAP ❑ ANALYTICAL DATA PROP 65/LIAR ❑ FILE CREATED <br /> 1p MANIFEST ❑ REFERRALS ❑ CLEANUP REPORT I ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />