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SAN JOAQUIN COUNTY <br /> A ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.'Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax;(209) 468-3433 - Web;www.sigov.org/ehd <br /> //�� <br /> EMERGENCY RESPONSE RECORD r <br /> DATE: V-fj MAI6- • SHORTTERM#: <br /> PREMISE ADDRESS: v CITY: <br /> DBA: rA W AQ CROSS STREET: 4a AhJ <br /> PREMISE OWNER: r PHONE: <br /> OWN ER'S ADDRESS: IM,ten �e CITY: <br /> FACILITY CONTAPHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: PHONE: J�/ <br /> RP ADDRESS: CITY: CK`--' i O <br /> RP CONTACT: 1 PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dump ial) <br /> Nf' qLk -i r -tel fi-� �cisS-P ' �- „ S <br /> f6ACi-q IAT <br /> TIME RECEIVED: 10 3k ' V ` TIME OF ARRIVAL: TIME OF DEPARTURE: AA <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> —rrdo SJC EHD <br /> APO `31,U <br /> /� , S fie,' trr� f�G•c�tlorlca D �D-7` /;,3p ,� -� <br /> MATERIAL/CLASSIFICATION(CHEMICAL NVOLVED) <br /> SOLID LIQUID GAS <br /> IDENTIFICATION SPILLED? (LBS) (GAL) (NFT) COMMENTS <br /> ❑N <br /> ❑Y o <br /> ❑Y o <br /> o o <br /> o o <br /> o o <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 ❑ NO <br /> ER BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ MAP ❑ ANALYTICAL DATA ❑ PROP 6S/LIAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT 1 ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />