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r u •co • SAN JOAQUIN COUNTY • <br /> H ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 600 E Main Street Stockton • CA 95202 <br /> r (209) 468-3420 • Fax: (209) 464-0138 • Web: www.sjgov.org/ehd <br /> 4� FORIn <br /> S '• <br /> EMERGENCY RESPONSE RECORD <br /> DATE: June 21,201 1 SHORT TERMCO003371 <br /> PREMISE 11530 W E ht Mile Road CITY: <br /> ADDRESS: g Stockton <br /> DBA' Kin Island Resort <br /> PREMISE OWNER: King Island Resort PHONE: <br /> 951-2188 <br /> OWNER'S ADDRESS: 11530 W Ei ht Mile Road CITY: Stockton <br /> FACB,ITY CONTACT: Np}e AtklnS-HarIJO master PHONE: 951-2188 <br /> RESPONSIBLE PARTY (RP) King Island Resort <br /> DBA: <br /> RP PHONE: <br /> NAME: <br /> RP ADDRESS: 11530 W Ei ht Mile Road CITY: Stockton <br /> RP CONTACT: Nate Atkins-Harbormaster PHONE: 951-2188 <br /> NATURE OF COMPLAINT(ex losion, spill,leak,fire, or abandoned/dumped material) <br /> Unknown person dumped gasoline into septage holding tanks. <br /> TIME 4:20 pm,6-20-11 TIME OF 1:00 pm,6-21-11 TIME OF DEPARTURE: <br /> RECEIVED: ARRIVAL; 1:45 pm,6-21-1 l <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Nate Atkins, Harbormaster King Island Resort 951-2188 1:00 m 1:45 m <br /> IDENTIFICATION OF MATERIAL(CHEMICAL[ v LWD) <br /> SUBSTANCE FORMSOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: I DATE MAILED: <br /> DATE COMPLETED....PROP 65: UAR; <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> none <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> H R -TERM 0 TOP NARRATIVE ANALYTICAL DATA 1PROP 65/UAR <br /> EXPOS RE RE RD ANIFES LEAN PREPOR RTS <br /> IHER AGENC REP <br /> REF MAP ILE REATED <br /> ER RECORD MODIFIED Page l of 05/01/2007 <br />