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SAN 3OAQUIN COUNTY <br /> s 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 /> EMERGENCY RESPONSE RECORD <br /> DATE: 19 <br /> 17 (� SHORTTERMk: ;J <br /> PREMISEADORESS: S• CITY; <br /> DBA: CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'SADDRESS: O ft CITY; <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: „, <br /> RP NAME: //�vi� PHONE: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> c#” w im4✓ dns�lN�/�/ zGSr lesu <br /> .ti JD was+ <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE Q Q <br /> SJC EHD <br /> r0—i(Gtr <br /> 5�'P <br /> MATERIAL/CLASSIFICATION la[uiu�wvavEOl <br /> �" IDENTIFICATION PILLS SOLID LI�1 lam COMMENTS <br /> Ft/ QI Y D N ^ <br /> a DN <br /> 0 a <br /> o DN <br /> m ON <br /> DY ON <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO fNAME AND ADDRESS) J} <br /> DATE PROP 65 COMPLETED: I I T DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? O YES ;plO <br /> ER BINDER <br /> SHORT-TERM ON TOP NARRATIVE MAP O ANALYTICAL DATA ED PROP 65/LIAR O FILE CREAT <br /> L <br /> MANIFEST D REFERRALS 1 ❑ CLEANUP REPORT O OTHER AGENCY REPORTS ❑ EXPOSURE RECORD NB/PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />