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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> . P (209) 468-3420 - Fax:(209) 468-3433 - We6:www.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: ZZZv (� SHORTTERM#: <br /> PREMISE ADDRESS: [[ ! 3o I L �� CITY: <br /> DBA: CROSS STREET: F <br /> �}Q <br /> PREMISE OWNER: PHONE: <br /> Q <br /> OWNER'S ADDRESS: Z II�� CITY: CA <br /> s-# <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA:PG&E <br /> RP NAME:PG&E PHONE:736-6426 <br /> RP ADDRESS:1108 Murphys Grade Road cITY:Angels Camp <br /> RP CONTACT:Alex Steele PHONE:736-6426 <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> M//,NL.P Oil Xx eM -p6e4 ,< <br /> cau 0 ri re <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> demA Jeffrey Wong SJC EHD (209) 468-0335 p a,su z I <br /> U� 33:7-39V- " o-..,t gzf- iZ <br /> g90 32 'QXI k-JI, ,A <br /> /z c 3: <br /> �►�� A 1.�.x -f - oZ zz s; <br /> MATERIAL/CLASSIFICATION(CHEMICALiNvaveD> <br /> IDENTIFICATION SPILLED? SOLID LIQUI GAS COMMENTS <br /> (LBS) (GAL) (CU FTI <br /> ❑Y N Y Q! if1 l"? Sr <br /> o c <br /> c ❑N <br /> ❑Y 11 <br /> pY nN <br /> REFERRALS AND NOTIFICATIONS <br /> REFERREDTO(NAME AND ADDRESS I DATE MAILED <br /> DATE PROP 65 COMPLETED: (i J DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> ORT-TERM ON TOP I RRATIVE MAP ❑ ANALYTICAL DATA PROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST p REFERRALS I ❑ CLEANUP REPORT ❑ OTHER AGENCY REPORTS 1 ❑ EXPOSURE RECORD OTOS <br /> ER RECORD Page 1 10/03/12 <br />