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P°"1" 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.sigov.org/ehd <br /> q <br /> ••a <br /> F1 <br /> EMERGENCY RESPONSE RECORD <br /> DATE: �I /f SHORT.TFRMri: CO00 9(0 b ' <br /> PREMISE ADDRESS: 14 D`L Wv ti CITY: <br /> DBA: uumf (.L L �.L CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP}DBA: L L G <br /> RP NAME: PHONE: <br /> RP ADDRESS: Cj // CITY: , <br /> RP CONTACT: 7 64,-� b PHONE: <br /> I , <br /> i NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: 7 <br /> Or a124 <br /> PERSONS AT SCENE <br /> I <br /> 1 NAME AGENCY PHONE TOA 'OD j <br /> SJC EHD <br /> d 7--?/-O-IL <br /> k& iSd , ti to S <br /> MATE RIAL/CLASSIACATION(CHEMICAL INVOLVED) <br /> IbSOLID LIQUID GASENTIFiCATION $PILLED? COMMENTS <br /> (LB5) (GAL) ICU FT) <br /> ►�t��tL4(,� Y ❑N Lwt <br /> ii ❑N <br /> a c <br /> ii o <br /> E3 ❑N <br /> o ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> i REFERREDTO(NAMEAND ADDRESS} DATE MAILED <br /> 1 <br /> ' DATE PROP 65 COMPLETED: DATE UAR COMPLETED: T <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE wr MAP ❑ ANALYTICAL DATA PROP 65/LIAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> 1 ER RECORD Page 1 10/03/12 <br />