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SAN JOAQUTN COUNTY <br /> z_ "2 ENVIRONMENTAL HEALTH 'DEPARTMENT <br /> 600 E Main Street Stockton ■ CA 95202 <br /> (209) 468-3420 - Pax: (209) 469-0138 - Web: www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD ` <br /> DATE: July 21;2008 SHORT TERM#: C00028703 <br /> PREMISE Country Club Blvd CITY: Stockton <br /> ADDRESS: <br /> DBA: Safeway Fuel Station <br /> PREMISE OWNER: Dennis Jacobsen Family Holding PHONE: 925 467-2217 <br /> OWNER'S ADDRESS: 23433 Hatteras St CITY: woodland Hills <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP PHONE: <br /> NAME: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: i PHONE: <br /> NATURE OF COMPLAINT(eosion, spill, leak,fire, or abandoned/dumped material) <br /> '/,I gallon of fuel spilled by customer at Dispenser#6 <br /> TIME 6:00pm TIME OF 6:15pm TIME OF DEPARTURE: 7:00pm <br /> RECEIVED: ARRIVAL: <br /> t PERSONS AT SCENE <br />! NAME AGENCY PHONE TOA TOD <br /> Julia Safeway On-scene On-scene <br /> Katie Store Manager) Safeway On-scene On-scene <br /> Marcus Store Mana er Safeway On-scene On-scene <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS v LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED._PROP 65: UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA I PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT I OTHER A ENCY REPORTS <br /> REFERRALS MAP FILE CREATED I i <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br /> e <br /> I <br />