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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420•Fax:(209)468-3433 ■ Web:www.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Monday May 7, 2012 SHORTTERM#: C00034942 <br /> PREMISE ADDRESS-T1 E3888 McKinley Ave CITY: Lathrop <br /> DBA: Superstore Industries <br /> PREMISE OWNER: same above PHONE: <br /> OWNER'SADDRESS: same above CITY: <br /> FACILITY CONTACT: Mike Young PHONE: 858-3468 <br /> RESPONSIBLE PARTY(RP)DBA: Superstore Industries <br /> RP NAME: Superstore Industries PHONE: 8558-3468 <br /> RP ADDRESS: 16888 McKinley Ave CITY: Lathrop <br /> RP CONTACT: Mike Young PHONE: 8558-3468 <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire,or abandoned/dumped material <br /> damaged oil filter on ice block maker machine released hydraulic oil into floor drain that leads to sewer lines but did <br /> not reach sewer. 1 <br /> I <br /> TIME RECEIVED: Sat 55/5112 TIME OF ARRIVAL: I Mon 5/7 1 OAM TIME OF DEPARTURE: 517 1030AM <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Mike Young Superstore Industries 858-3468 <br /> { <br /> IDENTIFICATION OF MATERIAL(CHEMICAL VOLVED) hydraulic oil I <br /> PHYSICAL STATE: ❑SOLID ❑POWDER []GAS iZ LIQUID []GRANULE <br /> REFERRALS TO: DATE MAILED: I <br /> DATE COMPLETED: PROP 65: NA. no release to waterway, dirt UAR: <br /> 1 <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE , <br /> na <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑YES ❑ NO <br /> E.R. BINDER COPIES: ! <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA El PROP 65 1 UAR <br /> EXPOSURE RECORD I Ej MANIFEST El CLEANUP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED 4 <br /> Rev.04/19/12 Page 1 of 3 Y ER Record <br /> i <br /> I <br /> } <br />