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sgt'`•t�L ••co SAN JOAQUIN COUNTY <br /> r a2 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 /> FORK <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 8/30/16 SHORTTERM#: C00042154 <br /> PREMISEADDRESS:85 E Louise Avenue CITY: Lathrop <br /> DBA: CROSS STREET: <br /> PREMISE OW NER: PHONE: <br /> OWNER'S ADDRESS: CITY:Lathrop <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA:Arco AM PM <br /> RP NAWE:Tefry PHONE:209 983 9144 <br /> RP ADDRESS: CITY:Lathrop <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> 8 Ounce of gasoline spilled on the concrete <br /> TIME RECEIVED: TIME OFARRIVAL: TIME OF DEPARTURE: <br /> PERSONSATSCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Muniappa Naidu SJC EHD <br /> MATERIALICLASSIFICATION Icremiuuxvaveol <br /> DENTIRCATION SPILLED? SOLID LIQUID GSR COMMENTS <br /> (LBS) GAD (N FT) <br /> Gasoline XY ❑N X <br /> DY ON <br /> ❑Y ON <br /> ❑Y ❑N <br /> ❑Y o <br /> ❑Y ON <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJ URED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ MAP ❑ ANALYTICAL DATA ❑ PROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEANUP REPORT ❑ OTHER AGENCY REPORTS 1 ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />