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SAN JOAQUIN COUNTY <br /> z 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: t SHORTTFP.M#: 0000 <br /> 3 <br /> PREMISE ADpRESS: f CITY: C � <br /> DBA' ,/ CROSS STREET: <br /> PREMISE OWNER: r i � PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: n' PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: 1J 9`ia1'� <br /> RP NAME: PHONE: <br /> RP ADDRESS: CiTYr <br /> RP CONTACT: PHONE: '7Drl " 3 p6�' S <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> czw <br /> TIME RECEIVED: ?j' ® TIME OF ARRIVAL: TIME OF DEPARTURE: - 3-6 <br /> PERSONS ATSCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJ C E H D <br /> Lv�n:v� A, 13N&ff4-60 -- 63D 6 <br /> MATERIAL/CLASSIFICATION ICHEMECALINVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS <br /> (LBS) (GAL) (CU FTI COMMENTS <br /> Y ❑N +fid <br /> ❑Y o <br /> ❑Y ❑N <br /> ❑Y c <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED 70(NAME AND ADDRESS DATE MAILED <br /> DATE PROP 65 COMPLETED: DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED, 'PERSONAL TOXICSUBSTANCE EXPOSURE RECORO"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> SHORT TERM ON TOP ek NARRATIVE MAP ❑ ANALYTICAL DATA ROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS 0 CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />