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A�u�N SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y'• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209) 468-3420 • Fax:(209)468-3433, Web:www.sfgov.orq/ehd <br /> r4 pR�y� - <br /> EMERGENCYRESPONSERECORD <br /> DATE: SHORT TERM#: <br /> e7 63L13 <br /> PREMISE ADDRESS. �D Si4 <br /> ( CITY: o <br /> el <br /> DBA: 5��k�.4. �a,,,. ►u.,� <br /> PREMISE OWNER: PHONE: r 7Qd <br /> OWNER'S ADDRESS: SIl� CITY: S f0 , <br /> FACILITY CONTACT: Q.I- k PHONE; 1Zol 4736 <br /> RESPONSIBLE PARTY(RP)DBA: SA�,4 <br /> RP NAME: PHONE: S <br /> RP ADDRESS: 15/4 CITY! S14 <br /> RP CONTACT: 5/k PHONE: S A <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire or abandoned/dumped material <br /> 6,1A 01&:.-c -Lak dAc s!"- Pte{ vp 1,;& a4 594A <br /> TIME RECEIVED: � U ,� TIME OFARRNAL: �.Ab �n TIME OF DEPARTURE: zz 0m .m—, <br /> PERSONS AT SCENE SAZA! 3 -Q q 0 <br /> if <br /> NAME AGENCY PHQWE TOA TOD <br /> T:0010. v <br /> Irb Att_ to1�t 236�'i n Y- 00 .4"- <br /> ak S.3 v y 12�30 .� iA%& % <br /> Sc.R 5�1 m L Y-7+6DD -f:v0 .k (,�._le- <br /> IDENTIFICATION OF MATERIAL(CHEMICAL WVCLVED) a4 O'&-!A. <br /> PHYSICAL STATE: ❑SOLID 0 POWDER L7 GAS VLIQUID 0 GRANULE <br /> REFERRALS TO: rj r&c, co"O-'3 DATE MAILED: UO ?-O 0 <br /> DATE COMPLETED; PROP 65: / -oSY UAR: p M <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> /(1 <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ©YES 0 NO <br /> -R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE M ANALYTICAL DATAPROP 65!LIAR <br /> EXPOSURE RECORD 0,MANIFEST CLEANUP REPORT El OTHER AGENCY REPORTS <br /> REFERRALS 0 MAP FILE CREATED <br /> Rev.44/19/12 Page 1 of 3 ER Record <br />