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oPqu'y oo SAN JOAQUIN COUNTY • <br /> Q' Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 600 E Main Street Stockton • CA 95202 <br /> (209) 468-3420 • Fax: (209) 464-0138 • web: www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD q �/ <br /> DATE: I I'//]](`Q�/y, I e SHORT TERM#:j,.� � 0000 J Z 8 b <br /> ADDRESS:PREMISE �{dr"t s' l"I� CITY: <br /> DBA: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: I/1/' CITY: 5 <br /> FACILITY CONTACT: PHONE: Gl 39 6t7q 0 <br /> RESPONSIBLE PARTY OM <br /> DBA: <br /> RP - PHONE: <br /> NAME: q <br /> t l <br /> RP ADDRESS: S, r CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, ill, leak, fire,or abandoned/dumped material) <br /> Y,IK Wx ar 0 6V%Pr . v�(W, 3 P/e/ M'+W6e 6v% <br /> 161-eeA, 5+�A �rP�l f o 4/U �o Cai leaf wl Fk- <br /> ML (-n`ae / ph (p3c183(3, & 5iie-fT rblm Ly <br /> TIME TIME <br /> REECEWED: I�-�1!/ f" ` ARRIVAL: OF a;Cv1y„�, TIME OF DEPARTURE:: <br /> PERSONS AT SCENE " <br /> NAME AGENCY PONE TOA TOD <br /> tfYvt �A,1 7� D <br /> IDENTIFICATION OF MATERIAL(cHawcN INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: t DATE MAILED: <br /> DATE COMPLETED....PROP 65: UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> E.R. BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE I ANALYTICAL DATA 1 PROP /UAR <br /> EXPOSURE KbuvRD MANIFE T ULbAN UP REPORT I OTHER A ENCY REPORTS <br /> Kht-hKKALZ MAP FILE CREATED <br /> ER RECORD MODIFIED Pagel of3 05/01/2007 <br />