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FILE COPY <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />c (209) 468-3420 • Fax: (209) 468-3433 - Web: www.sigov.org/ehd <br />EMERGENCY RESPONSE RECORD <br />DATE: <br />/ <br />SHORTTEW <br />Cade34 y� <br />PREMISE ADDRESS. S <br />CITY: <br />u <br />DBA: �GG/�Cfe.. [/�L,Q.T QNB <br />SAoLA <br />PREMISE OWNER:S <br />RP CONTACT: <br />S <br />PHONE: 205 V6;?- '1706 <br />OWNER'S ADDRESS: <br />S1A <br />r�ulC <br />CITY: S f0 •k— <br />FACILITY CONTACT: <br />�� <br />PHONE: <br />RESPONSIBLE PARTY (RP) DBA: <br />PHCUE <br />RP NAME: <br />TOD <br />PHONE: <br />S <br />RP ADDRESS: <br />S 4 <br />CITY: <br />1205- 5v6?-3YZ6 <br />RP CONTACT: <br />S <br />PHONE: <br />S <br />NATURE OF COMPLAINT (explosion, spill, leak fire or abandoned/dum ped material <br />6aA SMA . <br />Gaawl.,:,c <br />TIME RECEIVED: �p�, I TIMEOFARRfVAL: �:��I TIME OF DEPARTURE: LiLo�02 <br />PERSONS AT SCENE �hlJt i �f �Qtdi _ / -Q Q 'Ll <br />aIYL. 111 SA�.i <br />NAME AGENCY <br />PHCUE <br />TO <br />TOD <br />DATE COMPLETED: <br />PROP 65: <br />/ 3 - 0S YUAR: <br />&- S -J <br />1205- 5v6?-3YZ6 <br />vvo ,, <br />/0:ov . <br />c <br />.41.1,4 <br />10� 236-b'io <br />v y <br />�;oD <br />2 30 .� <br />r�ulC <br />LA6 /a CcAAA, biAj5�IVII <br />r2 vqL4-7,Paa <br />7-0 <br />IDENTIFICATION OF MATERIAL (cHEKvcw.urNoLvEc) 6"p-e—r l <br />PHYSICAL STATE: I ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br />REFERRALS T0: <br />'t, <br />DATE MAILED: <br />DATE COMPLETED: <br />PROP 65: <br />/ 3 - 0S YUAR: <br />A <br />PFRQ0klQ FYPIICGrl —Hlnr IN II lPPn <br />NAME ADDRESS <br />PHONE <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />❑ YES <br />❑ NO <br />E. R. BINDER COPIES: <br />SHORT-TERM ON TOP Pn NARRATIVE El ANALYTICAL DATA PROP 65 / UAR <br />❑ EXPOSURE RECORD I 4,MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br />❑ REFERRALS 1 9 MAP ❑ FILE CREATED <br />Rev. 04/19/12 Page 1 of 3 ER Record <br />