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/°'"I"•. SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton • CA 95205 <br />•P.• (209) 468-3420 •Fax; (209) 46$-3433 • Web. www.sjgov.orgCehd <br />EMERGENCY RESPONSE RECORD <br />RESPONSIBLE PARTY (RP) DBA: As above <br />RP NAME: PHONE: <br />RP ADDRESS: CITY: <br />RP CONTACT: PHONE: <br />NATURE OF RESPONSE (explosion, spill, leak, fire, or abandoned/dumped material) <br />TIME RECEIVED: <br />TIME OFARRIVAL: <br />TIME -Ir DEPARTURE: <br />PERSONS AT SCENE <br />NAME <br />AGENCY <br />PHONE <br />TOA <br />TOD <br />Elena Manzo <br />SJCEHD <br />209-953-7699 <br />10 am <br />11:40 am <br />Steve Rotondo <br />SFPUC <br />650-452-3962 <br />onsite <br />onsite <br />Anthony Scott <br />SFPUC <br />925-862-5711 <br />onsite <br />onsite <br />MATERIAL/CLASSIFICATION (CHEMICAL iWVl F" <br />IDENTIFICATION <br />Mercury <br />REFERRALS AND NOTIFICATIONS <br />SPILLED? I SOLID <br />X o <br />DY o <br />DY o <br />LiY D N <br />ii ❑N <br />DY ii <br />LIQ LI I D :r_A_S <br />(GALJ CU FT <br />2.3 <br />COMMENTS <br />*(grams) <br />IF PERSONS EXPOSED and/or INJURED, "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? -1 YES D NO <br />X SHORT-TERM ON TOP X NARRATIVE )( MAP C ANALYTICAL. DATA I X PROP 65 / UAR 12 FILE CREATED <br />X MANIFEST ❑ REFERRALS D CLEANUP REPORT I D OTHER AGENCY REPORTS I J EXPOSURE RECORD I X PHOTOS <br />ER RECORD Page 1 10/03/12 <br />