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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1.868 E. Hazelton Ave., Stockton - CA 95205 <br /> (209) 468-3420 • Fax:(209) 468-3433 - Web:www.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: a C21 3 SHORTTEP.MM C000 <br /> PREMISEADDRESS: 0.r -q�—PA fY'- CITY: : G <br /> DBA: C-Ll. CROSS STREET: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: y r <br /> � PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: {� a//��-C 1Ck nS O CkC& EdPS L <br /> RP NAME: Q AS C,�b(� v p— PHONE: q4 —q'g� <br /> RP ADDRESS: i 3 1"/t 4 C4 CITY: �y+� �^� <br /> RP CONTACT: n PHONE: gco Z•T <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> _-L rel ers p <br /> TIME RECEIVED: I ZOF I TIME OF ARRIVAL: [r I `� TIME OF DEPARTURE: r4 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD 8-03 2, ZO <br /> 4 — 9 h^ �x <br /> C e Wo —4'S <br /> Zj <br /> •A V <br /> MATERIAL/CLASSIFICATION(CKEMICAL INVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID 645 <br /> (LB5) (GAL) ICU FT) COMMENTS <br /> Y o <br /> ❑Y ❑N m yri A-w�&41 <br /> ❑Y ❑N voa S-�P— <br /> ❑Y ❑N drumsS( i <br /> o o r <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO!NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: 1 I DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? c YES ❑ NO <br /> ER BINDER COPIES: <br /> HORT TERM ON TOP JjV41ARRATIVE AP ❑ ANALYTICAL DATA PROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS 1 ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD HOTOS <br /> ER RECORD Page 1 10/03/12 <br />