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• i <br /> SAN JOAQUIN COUNTY <br /> 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 /> `�liFORN` <br /> EMERGENCY RESPONSE RECORD f <br /> DATE: �- ' �" I z / "CROSS <br /> TERMN: U Io <br /> PREMISE ADDRESS: S Z. 3J L.�OIF115 (CS <br /> DBA: 2- LPREMISE OWNER: E: <br /> OWNER'S ADDRESS: 7r�FACILITY CONTACT: �V) 9V1E: l'l • ZS✓ 3 <br /> RESPONSIBLE PARTY(RP)DBA: ZeLL461 vlawL <br /> RP NAME: PHONE: <br /> RP ADDRESS: JJ CITY: ,/ <br /> RP CONTACT: Gl PHONE: C4 <br /> NATURE OF RESPONSE(explosion,spill,leak,Fre,or abandoned/dumped material) <br /> l Bal Fa i,1 4 Cala v/M 0Mr!9AUCl* CauSed 6cnf*-er• tv Cd I ap Q r <br /> I. n tori le'r dwi nso tn(Plsif. <br /> TIMERECENED: TIMEOFARRIVAL: w Am TIME OF DEPARTURE: gf'I r•� <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Th L) SJC EHD T�o 61, <br /> I6TUI 030 <br /> MATERIAL/CLASSIFICATION(aEMIo INVOMD) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (Cu Fr) ��� <br /> N � 3 0 can wig cai6al <br /> DY ON <br /> DY ON <br /> DY CN <br /> DY ❑N <br /> DY ON <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: G DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? D YES D NO <br /> ER BINDER COPIES: <br /> D SHORT-TERM ON TOP D NARRATIVE 0 MAP D ANALYTICAL DATA 0 PROP 65/UAR o FILE CREATED <br /> D MANIFEST 0 REFERRALS 0 CLEANUP REPORT 0 OTHER AGENCY REPORTS 0 EXPOSURE RECORD 0 PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />