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0 <br /> SAN JOAQUIN COUNTY <br /> r _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> • P • (209) 468-3420 • Fax;(209) 468-3433 • Web;www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Monday, November 19, 2012 SHORTTERM#: C00035694 <br /> PREMISE ADDRESS: 16888 McKinley Ave Cin: Lathrop <br /> DBA:Super Store Industries CROSS STREET:Louise <br /> PREMISE OWNER:Super Store Industries PHONE: 858-3365 <br /> OWNER'S ADDRESS:P.O. Box 549, Lathrop CA 95330 CITY:Lath rop <br /> FACILITY CONTACT:Kelley Durrer(Plant Manager) PHONE:858-3365 <br /> RESPONSIBLE PARTY(RP)DBA:Super Store Industries <br /> RP NAME:Super Store Industries PHONE:858-3365 <br /> RP ADDRESS:P.O. Box 549, CITY:Lathrop <br /> RP CONTACT:Kelley Durrer (Plant Manager) PHONE:858-3365 <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> Approximately 2 gallons of anti-freeze was released on entrance driveway when hose on truck broke. <br /> TIME RECEIVED:12.20 TIME OF ARRIVAL: 1.25 TIME OF DEPARTURE:2:15 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> nI w T:f:ao SJC EHD ( <br /> <br /> On site <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GASCOMMENTS <br /> (LBS) (GAL) (CU FTI LL <br /> Y ❑N 0 <br /> o ❑N <br /> ii ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: W/qolz DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> X SHORT-TERM ON TOP X NARRATIVE X MAP ❑ ANALYTICAL DATA X PROP 65/LIAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD X PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />