Laserfiche WebLink
:........__..:............ .. _ -----------._..__. ......... _ = _ ............................ ............................. _ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> ( 09) 468-3420 • Fax:(209) 468-3433 • Web:www.sjgov.org/ehd <br /> (� EMERGENCY RESPONSE RECORD <br /> DATE: �— 4 � SHORT TERM#: <br /> ,� 7� <br /> PREMISE ADDRESS: v CITY: <br /> DBA: CROSS STREET: J <br /> PREMISE OWNER: r PHONE: <br /> OWNER'S ADDRESS: CITY: ~ <br /> FACILITY CONTACT: vs PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: ZD Vl,n <br /> ) <br /> RP NAME: PHONE: <br /> RP ADDRESS: ii CITY: T-m64CN <br /> RP CONTACT: I/� I PHONE: <br /> NATURE OF RESPONSE(explosic n,spill,leak,fire,or abandoned/dump Pial) <br /> Lj <br /> Nf— Tp ifs <br /> � 6ti�kL ,f t-,5 c l gat �;�,I led 'O Ah <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD <br /> /L U <br /> 91 OD If Kql q <br /> '�>-'ci 2412 <br /> E Q-*-W s ivvz_ /12. P. <br /> MATERIAL/CLASSIFICATION(CHEM:AL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GASCOMMENTS <br /> (EBS) (GAL) (Cu FT) <br /> ❑N <br /> ❑Y o <br /> o o <br /> o D <br /> ❑Y o <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATION <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 6S COMPLETED: DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJ RED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP ❑ NA RATIVE ❑ MAP ❑ ANALYTICAL DATA ❑ PROP 6S/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REF RRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />