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SAN JOAQUIN COUNTY <br /> z ?`' ENVIRONMENTAL HEALTH DEPARTMENT <br /> N; <br /> lot 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax:(209) 468-3433 • Web:www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD j <br /> DATE: — SHORT TERMi: C060 / J <br /> PREMISE ADDRESS: pf NCITY: <br /> Im i <br /> DBA: j CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: r <br /> RP NAME: ! e1L PHONE: <br /> RP ADDRESS: 110e, IM/ ' CITY: 2 <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> TIME RECEIVED: AVVTIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> 14M E AGENCY PHONE TOA TOD <br /> SJC EHD � )'ys <br /> C % 2x1 33i 49 b2, <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) <br /> ❑N <br /> o CN <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ii c <br /> ii c <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 INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? � YES I NO <br /> ER BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE MAP ❑ ANALYTICAL DATA PROP 65/UAR � FILE CREATED <br /> 0 MANIFEST L REFERRALS a CLEAN UP REPORT ❑ OTHER AGENCY REPORTS J EXPOSURE RECORD PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />