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s <br /> SAN JOAQUIN COUNTY ` <br /> ENVIRONMENTAL HEALTH DEPARTMENT T <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 /> i <br /> DATE:Wednesday, October 23, 2013 SHORTTERM#: CO0036862 j <br /> PREMISE ADDRESS: <br /> WEST LN CIn; Stockton <br /> i DBA:NA ICROSS STREET:MOSHER SLOUGH <br /> PREMISE OWNER:NA PHONE: NA <br /> OWNER'S ADDRESS:NA CITY:NA I <br /> NA PHONE:NA <br /> FACILITY CONTACT: <br /> RESPONSIBLE PARTY(RPI DBA:NA <br /> RP NAME:NA PHONE:N f <br /> RP ADDRESS:NA CITY:NA <br /> RP CONTACT NA PHONE:NA <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped material) <br /> TEST WATER AFTER FIREFIGHT. <br /> TIME RECEIVED:1300 TIME OF ARRIVAL: 1400 TIME OF DEPARTURE: 1500 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Jamie DeLaRosa SJC EHD (209) 953-6211 E <br /> I <br /> I <br /> I <br /> MATERIAL/CLASSIFICATION(CHEMJGL INVOLVED) <br /> i IDENTIFICATION SPILLED? SOLID H ID � COMMENTS j <br /> (LBS) (GAL) (CU FTI <br /> FIREFIGHT WATER XY ❑N UNKNN RUNOFF FROM FIREFIGHT l <br /> r aY ❑N <br /> ❑Y o <br /> u o <br /> o o <br /> i r <br /> o o <br /> s <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRE551 DATE MAILED <br /> NA NA <br /> NA NA <br /> s <br /> DATE PROP 65 COMPLETED: NA DATE UAR COMPLETED: NA <br /> IF PER50NS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> X SHORT-TERM ON TOP X NARRATIVE X MAP ❑ ANALYTICAL DATA ❑ PROP 65/UAR ❑ FILE CREATED <br /> ❑ MANIFEST ❑ REFERRALS, ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS ❑ EXPOSURE RECORD ❑ PHOTOS <br /> L ER RECORD•- Page 1 10/03/12 <br />