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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALT�I DEPARTMENT <br />�j 600 E Main Street Stockton ■ CA 95202 <br />(209) 468-3420 ■ Fax: (209) 464-0138 • Web: www.sjgov.org/ehd <br />0 <br />EMERGENCY RESPONSE RECORD <br />DATE: <br />102 -IL L O <br />S}IORT TERM//: <br />C000 <br />PREMISE <br />ADDRESS: <br />Z(`nyl l f+y �" " <br />CITY: <br />DBA: <br />LPly <br />r I <br />c Q� acHL I1/t� e, <br />PREMISE OWNER: <br />MAP <br />PHONE: <br />I FILECREATED <br />OWNER'S ADDRESS: <br />CITY: <br />FACILITY CONTACT: <br />R �jq�!> 1014, <br />P}TONE: <br />1 <br />152-2.2-L 3 <br />RESPONSIBLE PARTY (RP) C4-w� <br />DDA: <br />RP P}IONE: <br />NAME: <br />RP ADDRESS: CITY: <br />RP CONTACT: PIJONE: <br />INATURE U1, L:CIMYLAllN I (explosion, spiu, leak, we, or ananaonea/cnun a matermi) <br />(A,5f ' F 11 i � die8et-ayjwa6 it. quiv s1imf- d i5pela-%., Dass cita ro <br />Off <br />TIMEPJED: ( to C)OP � � TIME OF ,(? , TIME OF DEPARTURE: I 1 r�rj <br />ARRIVAL:! <br />PFRSCNQS AT .SCTXF. <br />NAME AGENCY PHONE TOAn� TOD <br />— — <br />pdvf�t <br />A bum u Hzt <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br />SUBSTANCE FORM I SOLID POWDER GA5 LIQUID GRANULE <br />REFERRALS TO: <br />NARRATIVEI <br />DATE MAILED: <br />I ANALYTICAL DATA <br />DATE COMPLETED .... PROP65: <br />Qa'g -I 1'-t o <br />UAR: <br />PERSONS EXPOSED and/or INJURED <br />I "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? I I YES I I NO <br />E. R. BINDER COPIES: <br />}] RT- M ON T P <br />NARRATIVEI <br />I ANALYTICAL DATA <br />PROP 65 / UAR <br />EXPOSURE RD <br />MANIFEST <br />UP REPORT <br />OT}TER AGENCY REPORTS <br />RE L <br />MAP <br />I <br />I FILECREATED <br />ER RECORD MODIFIED <br />Page I oF3 <br />05/01/2007 <br />