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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.sjgov.org/ehd <br /> �7 EMERGENCY RESPONSE RECORD <br /> DATE: J SHORTTERM#: <br /> PREMISE 'ADIDRESS: 0 C)a i �i G, Q CITY: <br /> ✓ <br /> DBA: t ict, ,_ y •I r �Q �� K CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: 4;V I ro <br /> RP NAME: ��IYnnY_e� PHONE: — Z✓ c�l� <br /> RP ADDRESS: O C) [rte o,,cy CITY: h <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD ;3� <br /> Y'tr_e Z G"c• Lit ` — (Z� U <br /> MATERIAL/CLASSIFICATION(CHEMI"L NVaveD) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) ICU FT) <br /> n ia.1 Y ❑N +.'F'cc v�i 6 y.57 <br /> o Li IN 15C•�� 1 .�. !CkE. <br /> ❑Y ❑N <br /> ❑Y u <br /> ❑Y ❑N <br /> o c <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 6S COMPLETED: I DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES O <br /> ER BINDER COPIES: <br /> c SHORT-TERM ON TOP ❑ NARRATIVE ❑ MAP ❑ ANALYTICAL DATA ❑ PROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST L REFERRALS CLEAN UP REPORT I a OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />