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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> kit 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax;(209) 468-3433 • Web;www.sjgov.org/ehd <br /> q�fFOiRa` <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Wednesday, March 11, 2015 SHORT TERM#: C6 (�� a SS I <br /> PREMISE ADDRESS:2072 W Yosemite Ave. CITY: Manteca <br /> DBA:Elite IV CROSS STREET:Airport Way <br /> PREMISE OWNER:GUINTA, FRANK JR TR PHONE: <br /> OWNER'SADDRESS:1892 OLIVEWOOD AVE MANTECA, CA 95336 CITY:Manteca <br /> FACILITY CONTACT:Pierre Chahoud PHONE:209 <br /> RESPONSIBLE PARTY(RP)DBA:Elite IV <br /> RP NAME:Chris Adams PHONE:209 461-6337 <br /> RP ADDRESS:3525 Wigwam Dr. CITY:Stockton <br /> RP CONTACT:Carrie Miller PHONE:209 461-6337 <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> Elite IV technician Chris Adams spilled approximately 7.5 gallons of fuel from the hose at dispenser#7. <br /> TIME RECEIVED:1.1 2pm TIME OF ARRIVAL: 1.45pm TIME OF DEPARTURE: 3pm <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Aris Veloso SJC EHD (209) 468-3453 1:45pm 3pm <br /> Pierre Chahoud Quick Shop 209 345-1689 <br /> Chris Adams Elite IV 209 461-6337 <br /> MATERIAL/CLASSIFICATION)CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LI UID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) <br /> fuel X Y ❑N 7.5 Chris Adams spilled some fuel. <br /> o o <br /> o ❑N <br /> o o <br /> o ii <br /> o [i IN <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESSI DATE MAILED <br /> DATE PROP 65 COMPLETED: DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCEEXPOSURERECORD"COMPLETED? � YES ❑ NO <br /> ER BINDER COPIES: <br /> E SHORT-TERM ON TOP X NARRATIVE )Q MAP ❑ ANALYTICAL DATA X PROP 6S/LIAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD X PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />