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SAN JOAQUIN COUNTY <br /> r " 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: (` ( U- ) SHORT TERM#: COOO t Lj-7-7 <br /> PREMISE ADDRESS: 01010 K,Zgt N I2 4� CITY: ( v, <br /> DBA: UP f 2 CROSS STREET: <br /> n <br /> PREMISE OWNER: (,IV PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: F <br /> RP NAME: Sic -% C--^ V PHONE: <br /> RP ADDRESS: G L St yl {1 CITY: <br /> RP CONTACT: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> U� U as ed gym e;. L en &t,Yk.,4 aGt.,C <br /> TIME RECEIVED: 12 30 TIME OF ARRIVAL: TIME OF DEPARTURE: AUlir,q <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Muniappa Naidu SJC EHD (209) 468-3439 2 3Z�A-" 6, . <br /> f ti 2 L art �i� <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) j J <br /> 1 LvlU [� ❑NZ /Y <br /> cY ❑N <br /> o o <br /> o o <br /> ❑Y o <br /> ❑Y o <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: It, /SL DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES c NO <br /> ER BINDER COPIES: <br /> �A SHORT-TERM ON TONARRATIVE ;EMAP ANALYTICAL DATA PROP 65/UAR ❑ FILE CREATED <br /> -MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS Cl EXPOSURE RECORD PHOTOS <br /> ER RECORD Pagel 10/03/12 <br />