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>,s <br /> .Ie ^ <br /> f "rN'.c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton - CA 95205 <br /> (209) 46$-3420 • Fax.(209) 468-3433 • Web. www.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Monday, November 19, 2012 SHORT TERM#: C00035694 <br /> PREMISE ADDRESS: 16888 McKinley Ave CITY: Lathrop <br /> DBA:Super Store Industries ICROSS STREET:Louise <br /> PREMISE OWNER:Super Store Industries PHONE: 858-3365'5 <br /> OWNER'S ADDRESS:P.O. BOX 549, Lathrop CA 95330 CITY:Lathrop <br /> FACILITY CONTACT:Kelley Durrer(Plant Manager) PHONE:858-33655 <br /> RESPONSiBLF PARTY{RP)DBA:Super Store Industries <br /> RP NAME:Super Store Industries PHONE:858-3365 a <br /> RP ADDRESS:P.O. BOX 549, CITY:Lathrop I: <br /> IRP CONTACT:Kelley Durrer (Plant Manager) PHONE:858-3365 <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> Approximately 2 gallons of anti-freeze was released on entrance driveway when hose on truck broke. <br /> ( <br /> i <br /> TIME RECEIVED:12.20 TIME OF ARRIVAL: 1.25 ITIME OF DEPARTURE:2.15 <br /> PERSONS AT SCENE <br />' NAME AGENCY PHONE TDA TOD <br /> nw T:faa SJC EHD (209) 468-0335 1:25 2:15 <br /> Kelley Durrer Super Store Industries 858-3365 On site j <br /> Tom Hughes Super Store Industries 858-3365 On site ; <br /> MATERIAL/CLASSIFICATION(CHEMIUL INVOLVED) <br /> GAS SOLID LI UID <br /> IDENTIFICATION SPILLED? SOLID COMMENTS { <br /> (LBS) (GAL) {CU FT} ytI <br /> A YL Y ❑N C I&P Aft ID <br /> ❑Y o i <br /> ❑Y o <br /> ❑Y u <br /> 13 c <br /> ❑Y ❑N <br /> i <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESSI DATE MAILED: <br /> DATE PROP 65 COMPLETED: W DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES j a NO <br /> ER BINDER COPIES: <br /> X SHORT-TERM ON TOP X NARRATIVE X MAP ❑ ANALYTICAL(IATA X PROP 55/UAR ❑ FILE CREATED <br /> ❑ MANIFEST 0 REFERRALS ❑ CLEANUP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD X PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />