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? SAN JOAQUIN COUNTY rn <br /> ENVIRONMENTAL HEALTH DEPARTMENT n ME appy <br /> 1868 E. Hazelton Ave., Stockton - CA 95205 <br /> \� (209) 468-3420 • Fax:(209) 468-3433 • Web;wwwsjgov.org/ehd <br /> .9ki*:�• <br /> \j.�li?/ <br /> EMERGENCY RESPONSE RECORD <br /> DATE: �� J S SHORTTERM#: ✓p3`i SSG <br /> PREMISE ADDRESS: (J �� �G/G�� CITY: <br /> DBA: (7 CROSS STREET: <br /> PREMISE OWNER: 1 ( l a �� PHONE: <br /> OWN ER'S ADDRESS: 20 ® CITY: lk � <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: n 42 q <br /> RP NAME: r / PHONE: 914 <br /> (-=S <br /> RP ADDRESS: ' / , CITY: � �J/�� C <br /> RP CONTACT: i ( PHONE: 2 C Z <br /> NATURE OF RESPONSE(explosion,spill,leall,fire,or abandoned/dumped material) <br /> LeAlc a-c- Ao5e,( Pt.,d -(; , 4ar1C_ oLI-., +nAe k - <br /> TIME RECEIVED: 112 a,-- I TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD Zj 551W"? b <br /> ;, <br /> MATERIAL/CLASSIFICATION(CHEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LI UID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) <br /> e VY m <br /> o o <br /> o o <br /> o o <br /> o ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: �� / DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES dCw0 <br /> ER BINDER COPIES: <br /> HORT-TERM ON TOP NARRATIVE ❑ MAP ❑ ANALYTICAL DATA PROP 65/LIAR FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT I ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD HOTOS <br /> ER RECORD Page 1 10/03/12 <br />