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o.p� `N•.c SAN JOAQUIN COUNTY <br /> r 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 /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM+►: <br /> laOr <br /> PREMISE ADDRESS: d 1 erFY: <br /> DBA: CR055 STREET: �} <br /> PREMISE OWNER: PHONE: 2_ <br /> OWNER'S ADDRESS: CITY: <br /> c /1 <br /> FACILITY CONTACT: �- PHONE: ALJ <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: a.M4. PHONE: <br /> RP ADDRESS: vN CITY; <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> -�b+' d t�'� �-C.^P, �e, 69m6, "�wj-i fffaY tl <br /> TME RECEIVED: TIME OF ARRWAL: TIME OF DEPARTURE: GtJ <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA i-op <br /> SJC EHD �- <br /> MATERIAL/CLASSIFICATION ICHEMiCALINVOIy[DI <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LRS) (GAll (CU FTI <br /> CAKtq0_C ❑N — {t ✓IS <br /> u o <br /> o ❑N <br /> ❑Y nN <br /> ❑Y ❑N <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO INAME AND ADDRES51 DATE MAIZE D <br /> DATE PROP 65 COMPLETED: DATE LIAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONALTOXICSUBSTANCEEXPOSURE RECORD"COMPLETED? ❑ YE5 ❑ NO <br /> ER BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE MAP ❑ ANALYTICAL DATA ❑ PROP 65/DAR FILE CREATED <br /> MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT n OTHER AGENCY REPORTS ❑ EXPOSURE RECORD PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />