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�o.•� .,D SAN JOAQUIN COUNTY M i '' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> �. ". (209)468-3420 • Fax:(209)468-3433 • Web:www.sigov.org/ehd <br /> JFORe� <br /> EMERGENCY RESPONSE RECORD y <br /> DATE: Z^ SHORT TERM N: JJS' <br /> PREMISE ADDRESS: OTY: <br /> DBA: CROSS STREET: OMAN <br /> PREMISE OWNER: (-L--- PHON cEE; <br /> OWNEWSADDRESS ��Zfl S Ex-t-4—A-V— Cm:f-^7m5w0 `)377,1 <br /> FACILITY CONTACT: yf I.,+ e. Y PHONE: _ <br /> RESPONSIBLE PARTY(RP)DBA:-+ L' <br /> RPNAME: PHONE: <br /> 619 <br /> RP ADDRESS: V CITY: <br /> RPCONTACT: PO 9,K (2,$56 , PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,orabandoned/dumped material'" 9377 <br /> TIME RECEIVED: q TIMEOFARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE JQ TOD <br /> SJCEHD <br /> �a 1-3 <br /> r- r-�r <br /> �S41 a t <br /> cr /0 i ,7 <br /> MATERIAL/CLASSIFICATION IWMMNVa DI <br /> IDENTIFICATIONp15 LLED7 ID LIQUID G� COMMENTS <br /> (Les (GAL) IN Fn <br /> oY ON <br /> DY oN <br /> UY ON <br /> ❑Y ON <br /> DY DN <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS 1 GATE MAILED <br /> DATE PROP 65 COMPLETED: 1_—)— 1DATE JAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? O YES o NO <br /> E BIND PIES: <br /> SHORT-'PERM ON TOP NARRATIVE MAP ❑ ANALYTICAL DATA ROP65JUAR o FILECREATED <br /> D MANIFEST Ci REFERRALS ❑ CLEANUP REPORT D OTHER AGENCY REPORTS ❑ EXP <br /> OSURE RECORD I olPHOTOS <br /> ER RECORD Page 1 10/03/12 <br />