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SAN JOAQUIN COUNTY <br /> IN. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> `a a 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax;(209) 468-3433 • Web:www.sjgov.org/ehd <br /> �<IFORt� <br /> EMERGENCY RESPONSE RECORD <br /> DATE: C' // SHORT TERM#: 3� <br /> PREMISE ADDRESS: ' "C CITY: <br /> DBA: y cc' <br /> -kyrc UeG Cps CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: 7 <br /> FACILITY CONTACT: a r PHONE: JUT 22 <br /> RESPONSIBLE PARTY(RP)DBA: I <br /> RP NAME: V PHONE: 5�� T - l� 15 22 <br /> RP ADDRESS: Z [A V � CITY: -r'Ci -Ft6Y� <br /> RP CONTACT: I`'` eA, w r C� z PHONE: 5- 01 - 522- ��5 TC <br /> 3 <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or aban ne1d/dumped material) (� <br /> S <br /> TIME RECEIVED: -%�A TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> L'`; C+"VLe- SJC EHD v3 ` :SO <br /> MATERIAL/CLASSIFICATION(aEMICAUNVOLeD) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) 1CU FT) <br /> / Y ❑N k <br /> I t t I <br /> o o <br /> o c <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 6S COMPLETED: I DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> D SHORT-TERM ON TOP RRATIVE AP ❑ ANALYTICAL DATA ROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS I ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />