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op gU±rn, <br /> c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w 1868 E. Hazelton Ave., Stockton - CA 95205 <br /> •rp . (209) 468-3420 - Fax: (209) 468-3433 - Web: www.sjgov.org/ehd <br /> c� Qa� <br /> EMERGENCY RESPONSE (RECORD <br /> -77/7 u <br /> DATE: ry i ��v��r�� f <br /> 2025 W. Hazelton Ave. l �� SHORT TERM#: C00036172 <br /> PREMISE ADDRESS: Stockton <br /> Headwaters Resources lr' <br /> DBA. Inc., Ventuura <br /> CROSS STREET: <br /> PREMISE OWNER:ISG Resources Inc. <br /> 951 Industry PHONE: {$01} 984-9400 <br /> OWNER'SADDRESS: ust ry Dr. Crry:Tukwila, WA <br /> FACILITY CONTACT:Brett Coulson <br /> PHONE;{916} 230-9350 <br /> RESPONSIBLE PARTY(RP)DBA:Headwaters Resources Inc. <br /> RP NAME: PHONE:(209) 469-0625 <br /> RP ADDRESS:2025 W. Hazelton Ave. CITY;Stockton <br /> RP CONTACT:Brett Coulson <br /> PHONE:l/ <br /> 916) 230-9350 <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> A silo of fly ash was overfilled for approximately 20 minutes, releasing the fly ash to the ground. <br /> TIME RECEIVED:1:50 PIA TIME OF ARRIVAL:3.40 PM PARTURE:4:00 PM <br /> TIME OF DE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Stacy Rivera SJC EHD (209) 468-3440 3:40 PM 4:00 PM <br /> Q _ "it . Gch 1c <br /> q88& 14 <br /> a <br /> MATERIAL/CLASSI FICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) ICU Fr) <br /> Fly ash X Y ,N 10,000 <br /> o ❑N <br /> o c <br /> ❑Y ❑N <br /> ❑Y cN <br /> :F- <br /> E3 ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS] DATE MAILED <br /> DATE PROP 65 COMPLETED: I DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES c NO <br /> ER BINDER COPIES: <br /> X SHORT-TERM ON TOP X NARRATIVE I X MAP ❑ ANALYTICAL DATA ❑ PROP 6S/LIAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS j ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS n EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />