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i <br /> j <br /> e•.`'�n• s SAN JOAQUIN COUNTY <br /> xf ENVIRONMENTAL HEALTH DEPARTMENT . <br /> iT 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209)468-3420 • Fax:(209) 468-3433 • Web:www.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD l <br /> DATE: �I?i' SHORTTERMM: 6-7 <br /> PREMISEADDRESS: ON0' <br /> 1t DBA: L, CROSS STREET: <br /> i PREMISE OWNER: �r w G^'IU PHONE: <br /> I OWNER'SADDRESS: ' v C v e+A CIN: !20-2,30 <br /> 1 G PHONE: Z- <br /> FACIUTY CONTACT: <br /> RESPONSIBLE PARTY(RP)DBA: XC'R/ ) 937,-7- <br /> � <br /> RP NAME: ` Co a PHONE• T3Z-tilO <br /> RP ADDRESS: —n G CITY: <br /> RP CONTACT: o• a PHONE: <br /> 1 NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> .T,>SCteI -C4eQ61t-e3e l 1p:111el— <br /> I <br /> r <br /> 1 TIME RECEIVED: 7 : T,o TIMEOF ARRIVAL: TIME OF DEPARTURE:. Tat <br /> PERSONSATSCENE <br /> MME AGENCY PHON Q Too <br /> SJC EHD <br /> I <br /> MATERIAL/CLASSIFICATIONIaLwuLmv ww <br /> 1 IDENTIFICATION p15 LIED7 SOLID MAD S$4 COMMENTS <br /> GPL la ETI <br /> IG7�l InCi� ❑N <br /> oY ON <br /> oY ON <br /> I ❑Y ON <br /> ❑Y ON <br /> o ON <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TD(NAME ANO AODRFSSI DATE MAILED <br /> DATE PROP 65 COMPLETED: -I /Z DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD'COMPLETED? ❑ YES &<0 <br /> ERB NDER COPIES: <br /> 11 HORT-TERM ON TOP NARRATIVE AP D ANALYTICAL DATA ROP 65/UAR ❑ FILE CREATED <br /> MANIFEST O REFERRALS O CLEANUP REPORT 0 OTHER AGENCY REPORTS I O EXPOSURERECORD I a4HOTOS <br /> ER RECORD Pagel 10/03/12 <br />