Laserfiche WebLink
�QI" •sSAN JOAQUIN COUNTY • <br /> Q ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> pi 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> . p (209) 468-3420 • Fax:(209) 468-3433 - Web.www.sjgov.org/ehd <br /> 91-/FORS` <br /> EMERGENCY RESPONSE RECORD <br /> DATE: I I(� r I SHORTTERMtF: <br /> PREMISE ADDRESS: <br /> �l 1-v. I Cl S' ;z- CITY: 1, <br /> DBA: Q Q[ < CROSS STREET: 1 U s <br /> PREMISEOWNER: CO bS (j t- A /• '_ PHONE: —3lp9—/lD <br /> J1t <br /> OWNER'S ADDRESS: ,S L �A\ ' S CITY: n1-`\ \(\( <br /> FACILITY CONTACT: \ k Oc V PHONE: p9O <br /> RESPONSIBLE <br /> �PARTY(RP)DBA: f' <br /> RPNAME: i C.-4ror PHONE:;,,)5 '" /O "� <br /> RP ADDRESS: C196&-1 CIN: <br /> RP CONTACT: I PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> go so O(Ae— 'j l kk A40(-I su.nt'Do b CL* 'Tbl uec 'yb � (Ylcnt�nq <br /> TIME RECEIVED: TIME OF ARRIVAL: ACTS �(� TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD C159-7;11 ;y ;ply <br /> U e C 46 &I r3 <br /> MATERIAL/CLASSIFICATION(UEMKALINMYED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (1-05) (GAL) (N FE) <br /> ❑N <br /> o DN <br /> ❑Y DN <br /> a a <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: Li DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> id SHORT-TERM ON TOP ,rl NARRATIVE MAP ❑ ANALYTICAL DATA ❑ PROP65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST n REFERRALS O CLEAN UP REPORT O OTHER AGENCY REPORTS O EXPOSURE RECORD PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />