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o?'a` •c SAN JOAQUIN COUNTY <br /> `ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton - CA 95205 <br /> (209) 468-3420 • Fax:(209) 468-3433 • web.www.sigov.org/ehd <br /> Coq, :a�P . <br /> J lFDR <br /> EMERGENCY RESPONSE RECORD <br /> DATE: illi3 SHORTTERIV#: Coo L 7� <br /> PREMISE ADDRESS: ( /r1 CITY: <br /> DBA: CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <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: t t` vv Grsv TIME OF ARRIVAL: j 30 TIME OF DEPARTURE: 2 DQ 1 M22 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA :TOD <br /> SJC EHD y-R `31'F3r <br /> Gov"-p- earn - ri Gj 3 e 6 z t 1 <br /> rl I 6212 <br /> 3 rz>digf 119 p Gly 4-1 <br /> MATERIAL/CLASSIFICATION(CHEMIULINVOLM) <br /> IDENTIFICATION SPILLED? SOLID LIQUID Gas(Les) (GAL) ICU Fr) COMMENTS <br /> ❑Y gN X <br /> [�ir/� ❑Y ❑N <br /> ❑Y u <br /> o ❑N <br /> o ❑N <br /> EiY n <br /> REFERRALS AND NOTIFICATIONS <br /> REFERREDTO NAMEANDADDRESS DATE MAILED <br /> DATE PROP 65 COMPLETED: OhAk () } DATE UAR COMPLETED: <br /> lA <br /> IF PERSONS EXPOSED and/or INJURED;"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? n YES ❑ NO <br /> ER BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ MAP ❑ ANALYTICAL DATA ❑ PROP 65/UAR C] E1LE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS D EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />