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SAN JOAQUIN COUNTY <br /> C. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> • cP (209) 468-3420 • Fax:(209) 468-3433 • Web;www.sjgov.org/ehd <br /> ��FORa <br /> EMERGENCY RESPONSE RECORD <br /> DATE: D — { <br /> [� 14 SHORT TERM#: • �1 <br /> PREMISE ADDRESS: CITY: <br /> DBA: I CROSS STREET: <br /> PREMISE OWNER: r + PHONE: <br /> OWNER'S ADDRESS: Sfftl lAAJ <br /> l ( CITY: <br /> FACILITY CONTACT: ^ ^ 1 C� PHONE: -26Ct•�ll rl zj <br /> RESPONSIBLE PARTY(RP)DBA: '1^_'Lril Ln <br /> n n .� S� G <br /> RP NAME: /.�IsP�(/T r) !1 PHONE •,� U �c Z_l MO <br /> RP ADDRESS: O S CITY: S <br /> RP CONTACT: 'a r PHONE: <br /> J <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> I�Ne ul AK" 4 6 6A e,+ to 'Tl I ,A�t <br /> StDfm ara-(n <br /> TIME RECEIVED: 1 TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD 'lqt& 'An' <br /> -1373--1 <br /> fie' D's03Z <br /> v r W.- <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LI UID GAS COMMENTS <br /> (LBS) (BALI (CU FTI <br /> f} ❑N ,lVF <br /> ❑Y ❑N - <br /> ❑Y ii IN <br /> o ❑N <br /> o c <br /> ❑Y o <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: I`1 DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES c NO <br /> ER BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ MAP ❑ ANALYTICAL DATA ❑ PROP 65/LIAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS I ❑ CLEANUP REPORT 1 ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />