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SAN JOAQUIN COUNTY <br /> H ; ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton•CA 95202 <br /> (209)468-3420•Fax.(209)464-0138• Web:www.sieov.ore/ehd <br /> FO <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 5-13 O 61 SHORT TERM#: C�OOryOO 107,Y�F - <br /> PREMISE 4'4'7M1POQ� i, (p,7� CI'[•y. S��I(',I I <br /> ADDRESS: W' ,_1 f.�l <br /> DBA: ACL <br /> PREMIS <br /> OWNERS f'rLI CVYLQ CC �n /1 PHONE: 403- /I�Lf00 )OOUp US6669 <br /> OWNER'sADDRESS: �+ �W� /I l K�IF-� CITY: S7U UG/0 " CEJ' /SZO <br /> FACILITY ��AA PHONE: <br /> m <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: �'YI <br /> RP NAME: Ad"IdPHONE: 1 tN S � 6669 <br /> RP ,- i CTTY: <br /> ADDRESS: LG L/-(F S Y v <br /> RP PHONE: <br /> CONTACT: f <br /> NATURE OF COMPLAINT(explosion,spill, leak, fire,or abandoned/dumped material <br /> i <br /> TIMEj - D T[ME OF ARRIVAL: 7. (� TIME DEPARTURE: OF <br /> RECEIVED: I'Z' (to two <br /> (9 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> pa <br /> HLi4 a,19 3 19 0) <br /> reAm 10 <br /> IDENTIFICATION OF MATERIAL(coeM¢ALwvoweD) <br /> �OBRSMTANCE LID POWDER GAS LIQUID GRANULE <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP UA <br /> 65: R: IIII <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> I <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page i of 4 05/01/2007 <br />