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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ., 3868 E. Hazelton Ave., Stockton - CA 95205 <br /> (209) 468-3420 • Fax:(209) 468-3433 • Web.-www.sjgov.org/ehd <br /> QCi�Qui' <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Z" SHORT TERM#: CJS <br /> PREMISE ADDRESS: T 1 1 %•J CITY: <br /> DBA: CROSS STREET: <br /> PREMISE OWNER: ,ti L L.c PHONE: <br /> OWNER'S ADDRESS: 7-E37ie S CITY:!F-�5M0CA <br /> FACILITY CONTACT: �• lor.' Gn PHONE: <br /> RESPONSIBLE PARTY(RP)aBA: <br /> RP NAME: PHONE:Zc7 rj "�jr-> <br /> RP ADDRESS: 1 < (•I CITY: <br /> RP CONTACT: Ain! �a o rj PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material)CA (737-? <br /> TIME RECEIVED: TIME OF ARRIVAL: 15-2t> q TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD SD <br /> 71'96'7- ;yam <br /> o- P1.14 Aar-- <br /> L y^ !Q fl-,-o J <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> D <br /> IDENTIFICATION SPILLED? SOLID LIQUIGAS(LBS) (GALS =FT) COMMENTS <br /> %/Y ❑N Ivoo/b <br /> L ❑Y [3 IN <br /> ❑Y ❑N <br /> ❑Y o <br /> ❑Y m <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERREDTO(NAMEAND A01I DATE MAILED <br /> DATE PROP 65 COMPLETED: -1- 1,3 DATE VAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> E BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE MAP ❑ ANALYTICAL DATA ROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD Cr,PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />