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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax: (209) 458-3433 • Web: www.sjgov.org/end <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORTTERMN: <br /> PREMISE ADDRESS: I CITY: <br /> DESA: _.l'& CftOS55TREET: <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: } <br /> <br /> <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> tyl <br /> TIME RECEIVED: ` TIME OF ARRIVAL: TIME OF DEPARTURE:, VA 1 L <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD NA— <br /> ) <br /> I � <br /> MATERIAL/CLASSIFICATION(aeA"wLNVaWDo <br /> IDENTIFICATION SPILLED? SQL) LIQUID GAS COMMENTS <br /> IL®S) (GAL) (CU FT) <br /> I ❑NU. <br /> a ❑N i4 , rll y f <br /> o o <br /> ❑Y uN <br /> LiY ❑N <br /> D o <br /> REFERRALS AND NOTIFICATIONS <br /> RfFfRRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: ✓ DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES o NO <br /> £R DINDER COPIES: <br /> LN SHORT-TERM ON TOP NARRATIVE MAP ANALYTICAL DATA PROP 65/LIAR o FELE CREATED <br /> MANIFEST ❑ REFERRALS ❑ CLEANUP REPORT L1 OTHER AGENCY REPORTS ❑ EXPO5URE RECORD I &,PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />