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oP " SAN JOAQUIN COUNTY <br /> Z :z" ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Man Street Stockton •CA 95202 <br /> . <br /> '..,.�.�� (209)468-3420•Fax:(209)4653433 • Web:www.si4ov.orNehd <br /> ,a,";j., <br /> EMERGENCY RESPONSE RECORD <br /> DATE: MOWNERCOSWO <br /> Monday, J*11, 2011 SHORT TERM x®03 a®(p <br /> PREMIS16 Hammer Lane CITY: Stockton <br /> DBA: <br /> PREMISPHONE: (209)478-2040 <br /> OWNER' 16 Hammer Lane CITY: StOCIdDn <br /> FACILITthew Barge PHONE: (209)478-2040 <br /> RESPONSIBLE PARTY(RP)DBA: COsico <br /> RP NAME: PHONE: <br /> RPADDRESS: 1616 Hammer Lane CITY: Stockton <br /> RP CONTACT: Mathew Barge PHONE: (209)478-2040 <br /> NATURE OP COMPLAINT(explosion, ll, leak,fire,or abandoned/dum material <br /> 100 gaHorts of gasoline leaked out of the 91 primary tank during a schedule repair at the gas staton. 53 gaRans of <br /> the release went into the storm drain. <br /> TIME RECEIVED: 8.45 am TIME OF ARRIVAL: 9.00 am TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOO <br /> Muniappa Naidu SJC EHl3 (209)468-3439 9.00 am <br /> Mathew Barge Costco (209)4752040 <br /> Rai 11 1'I <br /> Mike It tC <br /> 1448-kj;0kAWLA, S50"I'v> 9:no <br /> IDENTIFICATION OF MATERIAL(c w+ i v Lv D) Gasoline- 91 Octane <br /> PHYSICAL STATE: ®SOLID 0 POWDER ®GAS 19 LIQUID CCRANME <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP65: JW 11, 2011 UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> NA <br /> °PERSONAL TO)OC SUBSTANCEEWOSIIRERECORV COMPLETEDq EJ YES ONO <br /> E.R.BINDER COPIES- <br /> SHORT-TERMONTOP NARRATIVE ANALYTICAL DATA PROP65/UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT OTHER AGENCY REPORTS <br /> REFERRALS U FILE CREATED <br /> Rev.08/16/10 Page 1 of 3 ER Record <br />