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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) 468-3433 • Web: wwwsjgov.org/ehd <br /> Cf�cpp� <br /> EMERGENCY RESPONSE RECORD �/� Oj <br /> DATE; � y SHORT TERMSCO W • <br /> PREMISE ADDRESS: -� J �vf' CITY: <br /> DBA: CROSS STREET; <br /> PREMISE OWNER: '' PHONE: <br /> OWNER'S ADDRESS: ' CITY: Fccalal <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: �- <br /> RP NAME: G Vac CG PHONE: <br /> RP ADDRESS: �j CITY: ^, <br /> RP CONTACT: PHONE: <br /> NATURE OF RE ONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> 1�4 <br /> A�w+�wnrd.� °� ► ,�t.�, L C'uC, <br /> ky,- <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PFRSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC PHD <br /> IC. , C ,S <br /> MATERIAL/CLASSIFICATION tEw Aiu+Ya vt�l <br /> IDENTIFICATION SPILLED? SOLID. L QVLD GAS COMMENTS <br /> (LBS) (GAL) ICU F7) <br /> ! L�7 ❑N <br /> ❑Y c <br /> ❑Y ❑N <br /> c3 LAN <br /> mY o <br /> DY c <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: U DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES ❑ NO <br /> ER BINDER COPIES: _ <br /> C', SHORT-TERM ON TOP C NARRATIVE ❑ MAP a ANALYTICAL DATA ❑ PROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 10/03/12 <br />