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SAN 3OAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> �. (209)468-3420 • Fax.(209) 468-3433 • Web.www.sjgov.org/ehd <br /> IPIi <br /> EMERGENCY RESPONSE RECORD <br /> DATE: I • 015-- SHORTTERM#: G ��37So7 <br /> PREMISE ADDRESS: Lobb 0 CITY: caq <br /> DBA: CROSS STREET: r <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: A -QyQ PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: {'' PHONE: <br /> RP ADDRESS: [ODD G OTY: <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> -FWo 4'Jp, bq(85 UII *A 7G0 '0 f9{e O�— SmiLft fu6-z�e 4uris CIAfM& <br /> due fl) 0C ,;n0LdQqVA4#1 CIYJQr'Qg U,ndW W►P.n leak sta�ied <br /> dice*mA c fffl arrtiVu tD <br /> TIME RECEIVED: TIME OF ARRIVAUSA TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD <br /> mle�ut <br /> MATERIAL/CLASSIFICATION lartrraixvarEnl <br /> IDENTIFICATION SPIT EDI IS=1 IuQul ICU <br /> COMMENTS <br /> ❑N 2 �cj} <br /> n o <br /> u ON <br /> o o <br /> u o <br /> OY ON <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO MME AND ADDRESS I DATE MAILED <br /> DATE PROP 65 COMPLETED: - I DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOX/CSUBSTANCE EXPOSURE RECORD"COMPLETED? O YES ONO <br /> E DER OPIES: <br /> o SHORT-TERMONTOP O NARRATIVE ❑ MAP O ANALYTICAL DATA ❑ PROP 65/UAR ❑ FILE CREATED <br /> u MANIFEST o REFERRALS u CLEAN UPREPORT 1 O OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />