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SAN JOAQUIN COUNTY <br /> r y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> ' (209) 468-3420 • Fax.(209) 468-3433 • Web:www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORTTERM#: OY <,)00,3067 <br /> PREMISE ADDRESS: o5 ' CJ j- 2� CITY: <br /> DBA: L CR S STREET: <br /> PREMISE OWNER: ,� ��� / PHONE 2IAI S_ <br /> c <br /> OWNER'S ADDRESS: C2, CITY: C <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: e- <br /> C•rrpi r� �� G -J <br /> RP NAME: {tea R L t c L( ONE-2tA� 7IS •3 <br /> -05�tr7 lis - / <br /> RP ADDRESS: r,U, 1191-2 i •z, -11✓il1)e, Ut-1 i' CITY= e-ho S"Z06 <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> }ri(`e. i} �� )) �.r �(t�a�inz-F,.kor �� � :/rte-S� �sh.� D., �i��l� ��i`�ee.�_ <br /> TIME RECEIVED: Z��O ,_ TIME OF ARRIVAL: �j Zl✓r ;__ TIME OF DEPARTURE: /O <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Garrett Backus SJC EHD (209) 468-2986 <br /> 3- - 2+67-Si+c <br /> Frl i,� <br /> C r L - GG 1 cri -)4 -5613i�--- <br /> /- �' �' ear J� '�Gr-�.. -C• - <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FTI <br /> i <br /> ❑Y o <br /> o o <br /> o c <br /> o ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: J ( /-3 DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER RINDER COPIES- <br /> SHORT-TERM ON TOP ARRATIVE VKAP ❑ ANALYTICAL DATA PROP 6S/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS qtLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD HOTOS <br /> ER RECORD Page 1 10/03/12 <br />