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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax;(209)468-3433 • Web.-www.sjgov.org/ehd <br /> n EMERGENCY RESPONSE RECORD <br /> DATE: 10-al- pq C 1 I SHORT TERM#: <br /> (� C� <br /> PREMISEADDRESS: �J ;-� , CITY: <br /> DBA: S VQ-5 CR(O�SS STREET: <br /> PREMISEOWNER: aW IVO1(�j (l +GL U P- PHONE: <br /> DR <br /> OWNER'S ADDRESS: 40 11 ` CITY: Yl 1 uo <br /> FACILITY CONTACT: N � 1PHONE: (00 ` <br /> 60623 <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: PHONE: <br /> RP ADDRESS: (Q'S_L4 0 4VU ' •) CITY: n^C <br /> L+ip In <br /> RP CONTACT: PHONE: W9 C)l <br /> NATURE OF RESPONSE(exp osion,spill,leak,fire,or abandoned/dumped material) <br /> A�������Q.©l cow a�S�h c�.Q,� � -�h,�. <br /> r 8 c,A.C, r,ci ��av�po <br /> TIME RECEIVED: Gr I/ TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONSATSCENE /V Q <br /> NAME AGENC PHONE TOA TOD <br /> SJC EHD <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) <br /> Y ❑N L <br /> o c <br /> o o <br /> D o <br /> o o <br /> o ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: W I DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES NO <br /> R BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE MAP ❑ ANALYTICAL DATA ❑ PROP 65/UAR 11 FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT 1 ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />