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U <br /> q4 !N` 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.sjgov.org/ehd <br /> C/FORS <br /> � ��"" EMERGENCY RESPONSE RECORD <br /> 7 <br /> DATE: 3 SHORTTERM#: •D 3-72(a� <br /> PREMISEADDRESS: <br /> CITY: <br /> DBA: <br /> CROSS STREET: <br /> PREMISEOWNER: <br /> PHONE: <br /> OWNER'SADDRESS: <br /> CITY: <br /> FACILITY CONTACT: <br /> PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: <br /> PHONE: <br /> RPADDRESS: <br /> CITY: <br /> RP CONTACT: <br /> PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fi e,or aba ndoned/dumped material) <br /> oOku /1l L/o�x-aJ e� 10 <br /> ✓til d ala"�7. <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY <br /> DPHONE TOA TOD <br /> Z <br /> l3reclr <br /> MATERIAL/CLASSIFICATION(cHEmiCLlR LwDI <br /> IDENTIFICATION SPILLED? LID LIQUID <br /> (LBS (GAL) ICU COMMENTS <br /> ❑N ❑ ❑ <br /> ❑Y ON ❑ ❑ <br /> ❑Y ON ❑ ❑ ❑ <br /> ❑Y ON ❑ ❑ ❑ <br /> ❑Y ON ❑ ❑ ❑ <br /> El ❑N ❑ ❑ ❑ <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED 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? <br /> DYES ONO <br /> ER BINDER COPIES: <br /> ORT-TERM ON TOP RRATIVE MAP NALYTICAL DATA ❑PROP 65/UAR ❑FILE CREATED <br /> ❑MANIFEST ❑REFERRALS ❑CLEAN UP REPORT ❑OTHERAGENCY REPORTS ❑EXPOSURERECORD PHOTOS <br /> ER RECORD <br /> Page 1 10/03/12 <br />