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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> :kw1 ` 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> �. r (209) 468-3420 • Fax:(209) 468-3433 • Web:www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: —7,7-fLl SHORTTERM#:<f_,o 7 f <br /> PREMISE ADDRESS: 1 CITY: <br /> DBA: CROSS STREET: <br /> PREMISE OWNER: Ct 1'tn + PHONE: .Z& �31 Y3�J? <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: J - PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: G <br /> RP NAME: PHONE: <br /> RP ADDRESS: 'I CITY: <br /> RP CONTACT: trZJ PHONE: -�! ` <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,oryabando(nn�ed/dum/Ip-ed matte Ial) <br /> �t�jc�s�cr-c� •v� (`j hnw-��^�'� �,�li.�ra'�'J� l,�F?2T- '7� � � Gi it . <br /> U c�c'27w� <br /> TIME RECEIVED: TIME OF ARRIVAL: J - TIME OF DEPARTURE: - -I <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 4 SJC EHD _ I15a �- <br /> cul 0-C a 1,v10"'l-931- i `^ c <br /> 2. r�Y�s <br /> G ti�ai ti 0tre- <br /> -7-6G -ewo 0 <br /> MATERIAL/CLASSIFICATION(CHEMICAL NVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) <br /> .^ n Y ❑N <br /> ,• >PY ❑N qC0 . <br /> ❑Y o <br /> ❑Y o <br /> ❑Y ❑N <br /> ❑Y o <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 TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES NO <br /> E INDER COPIES: <br /> SHORT-TERM ON TOP ARRATIVE WIMAP ❑ ANALYTICAL DATA ROP 65/LIAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD HOTOS <br /> ER RECORD Page 1 10/03/12 <br />