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� SAN JOAQUIN COUNTY <br /> ,�....lN <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> bit 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209) 468-3420 • Fax:(209) 468-3433 - Web:www.sjgov.org/ehd <br /> 9�/F[iiR� <br /> EMERGENCY RESPONSE RECORD ll <br /> DATE: c y� fJ SHORTTERM#: �(JV <br /> PREMISE ADDRESS: CITY: G � <br /> DBA: CROSS STREET: <br /> PREMISE OWNER: � fz / PHONE: <br /> OWNER'S ADDRESS: D CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: �Gt��S PHONE: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> wk4o- U'`' Ali �m& r d,45 q/✓-GleeIIL <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SJC EHD <br /> MATERIAL/CLASSIFICATION(CHEMICAL NVOLVED) <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (CU FT) <br /> Q� Y ❑N '` <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> o c <br /> ❑Y c <br /> ❑Y u <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: 1 / DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXJCSUBSTANCEEXPOSURERECORD"COMPLETED? YES O <br /> ER BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE V MAP ❑ ANALYTICAL DATA PROP 65/UAR ❑ FILE CREATED <br /> _i MANIFEST ❑ REFERRALS 1 ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS v EXPOSURE RECORD PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />