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pPpUlry. C SAN JOAQUIN COUNTY <br />= ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton • CA 95205 <br />(209) 468-3420 • fax. (209) 468-3433 • Web: www.sjgQv.org/ehd <br />EMERGENCY RESPONSE RECORD <br />DATE: 1-27-1 <br />PREMISE ADDRESS: 2440 Daniels St. Manteca, CA 95336 <br />DBA: Costco <br />PREMISE OWNER: C'oStCO Wholesale Corporation <br />OWNER'S ADDRESS: 999 Lake Dr. Issaquah, WA 98027 <br />FACILITY CONTACT: Charle Morris <br />RESPONSIBLE PARTY (RP} DBA: Costco Wholesale Corporation <br />RP NAME: Charle Morris <br />RP ADDRESS: 2440 Daniels St. Manteca, CA 95336 <br />RP CONTACT: Charle Morris <br />SHORTTERM9: 000040983 <br />CITY: Manteca <br />CROSS STREET: Milo Candinl <br />PHONE: (209) 825-8200 <br />CITY: Manteca <br />PHONE: (209) 825-8200 <br />PHONE: <br />CITY: Manteca <br />PHONE: (209) 825-8200 <br />NATURE OF RESPONSE (explosion, spill, leak, fire, or abandoned/dumped material) <br />Received a spill notification from Rob with 3E (800) 451-8346 that a four gallons of fuel spilled from a <br />customer's fuel tank. <br />TIME RECEIVED: 2.30 PM <br />TIME OF ARRIVAL: 3:30 PM TIME OF DEPARTURE: 4:15 PM <br />NAME <br />ris Veloso <br />AGENCY <br />SJC EHD <br />PHONE <br />(209) 468-3453 <br />TDA <br />3:30PM <br />TOD <br />Stacy Rodrigues <br />Costco <br />(209) 825-8200 <br />Charle Morris <br />Costco <br />(209) 825-8200 <br />MATERIAL/CLASSIFICATION ictimuLmvmv-i <br />IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br />(LBS) (GAL) ICU FT) <br />gasoline XY U N 4 <br />❑Y ❑N <br />❑Y EN <br />❑Y ❑N <br />11 ❑N <br />n ii <br />REFERRALS AND NOTIFICATIONS <br />REFERRED TO (NAME AND ADDRESSI DATE MAILEQ <br />DATE PROP 65 COMPLETED: 1-28-16 1 DATE LIARCOMPLETED: <br />iF PERSONS EXPOSED and/ar INJURED, "PERSONA! TOXJC SUBSTANCE EXPOSURE RECORD°` COMPLETED? ❑YES ❑ NO <br />� SHORT-TERM ON TOP �i NARRATIV�EMMAP ❑ANALYTICALDATA <br />MANIFEST ❑CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br />ER RECORD Page 1 <br />X PROP 65 / UAR 1 ❑ FILE CREATED <br />❑ EXPOSURE RECORD I X PHOTOS <br />10/03/12 <br />