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-41 SAN JOAQUIN COUNTY <br /> 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 /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM#:C O <br /> PREMIS ADDRES CITY: <br /> DBA: CROSS STREET: G <br /> PREMISE OWNER: / PH E;'v ` <br /> OWNER'S ADDRESS: CITY <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: <;1A PHONE: S <br /> RP ADDRESS: 5j `"'b CITY: S � <br /> RP S CONTACT: PHONE: A <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> 0-2,0 &As . -#zt �s �, IP <br /> TIME RECEIVED: §:/S/S/1— TIME OF ARRIVAL: Q TIME OF DEPARTURE: Q .�- <br /> PERSONS AT SCENE <br /> i <br /> NAME AGENCY PHONE TOA TOD <br /> /<A)d LL-- SJC EHD C q : ZD Z - 30 <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FTI <br /> LTi Y ❑N <br /> ❑Y ❑N <br /> ❑Y o <br /> ❑Y ❑N <br /> ii ❑N <br /> o ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: 40 DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER INDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE MAP ❑ ANALYTICAL DATA PROP 65/LIAR ❑ FILE CREATED <br /> Ip MANIFEST ❑ REFERRALS ❑ CLEANUP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />