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¢ <br /> (­44'a" <br /> SAN JOAQUIN COUNTY <br /> 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 /> [JH / <br /> EMERGENCY RESPONSE RECORD <br /> DATE: (7,1111) SHORTTFRM#.- COOO 3rj�g�' <br /> PREMISE ADDRESS: -7 6 SIV CITY: s"IU � <br /> DBA: So CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'SADDRESS: S CITY: S�bG <br /> FAClUTYCONTACr )CW K1, PHONE:(7.,f4) Z?j -- Y(OI <br /> RESPONSIBLE PARTY(RP)DBA: 9" <br /> I RP NAME: PHONE: <br /> RPADDRESS: CITY: <br /> RP CONTACT:. PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> /k 0 Jb fl �ls re�c icQ 4,��1" .-r^ r fv <br /> TIME RECEIVED: TIMEOFARRIVAL: pO TIME OF DEPARTURE: <br /> PERSONS ATSCENE <br /> NAM AGENCY PHONE TOA TOD <br /> SJC EHD <br /> MATERIAL/CLASSIFICATION IaearxnAum) <br /> IDENTIFICATION SPILLED? SOUP UQUID 965 IGAU I m COMMENTS <br /> i o ON <br /> OY ON <br /> o ON <br /> o ON <br /> o DN <br /> �. D ON <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: IZ ./ DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXICSUSSlANCE EXPOSURE RECORD"COMPLETED? 0 YES O NO <br /> ER BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP O NARRATIVE . O MAP O ANALYTICAL DATA C PROP 65/UAR C FILE CREATED <br /> ❑ MANIFEST C REFERRALS O CLEAN UP REPORT O OTHER AGENCY REPORTS O EXPOSURE RECORD C PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />