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SAN JOAQUIN COUNTY z ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton • CA 95205 09) 468-3420 • Fax: (209) 468-3433 • Web; www.sigov.org/ehd •c EMERGENCY RESPONSE RECORD RESPONSIBLE PARTY (RP) DBA: V gyo V`G RP NAME: PHONE: RP ADDRESS: CITY: RP CONTACT: PHONE: NATURE OF RESPONSE (explosio i, spill, leak, fire, or abandoned/dumped material) &ec, `wx- f i u rJU vjKjj m GGmwrt (tel ewSe, TIME RECEIVED: TIME OF ARRIVAL: I TIME OF DEPARTURE: NAME AGENCY PHONE 7 2013 h� '- h SJC EHD SPILLED? DATE: AA (Lk — tw IDENTIFICATION M#: ✓�`L� Q� ??-z>SHORTTEC,R 5� sf CITY: PREMISS ADDRESS: O r G ✓�� DBA: ❑Y ❑N CROSS STREET: PREMISE OWNER: ❑Y ❑N PHONE: ❑Y ii o o OWNER'S ADDRESS: o o CITY: FACILITY CONTACT: PHONE: RESPONSIBLE PARTY (RP) DBA: V gyo V`G RP NAME: PHONE: RP ADDRESS: CITY: RP CONTACT: PHONE: NATURE OF RESPONSE (explosio i, spill, leak, fire, or abandoned/dumped material) &ec, `wx- f i u rJU vjKjj m GGmwrt (tel ewSe, TIME RECEIVED: TIME OF ARRIVAL: I TIME OF DEPARTURE: NAME AGENCY PHONE TOA TOD h� '- h SJC EHD SPILLED? SOLID LIQUID AA (Lk — tw IDENTIFICATION (LBS) (GAL) (CU FT) d ❑N REFERRED TO (NAME AND ADDRESSI DATE MAILED SPILLED? SOLID LIQUID GAS COMMENTS IDENTIFICATION (LBS) (GAL) (CU FT) d ❑N ❑Y ❑N ❑Y ❑N ❑Y ii o o o o REFERRED TO (NAME AND ADDRESSI DATE MAILED DATE PROP 65 COMPLETED: 6-1113) DATE UAR COMPLETED: IF PERSONS EXPOSED and/or IN1 iRED, "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO ER BINDER COPIES: ❑ SHORT-TERM ON TOP ❑ NAR ATIVE ❑ MAP ❑ ANALYTICAL DATA ❑PROP 6S / UAR ❑ FILE CREATED ❑ MANIFEST ❑ REF RRALS ❑ CLEANUP REPORT ❑ OTHER AGENCY REPORTS I Cl EXPOSURE RECORD ❑ PHOTOS ER RECORD Page 1 10/03/12