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I <br /> x FD SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> d w (209)468-3420 - Fax: (209) 468-3433 • Web: www.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: D SHORTTERMN; <br /> PREMISE ADDRESS: O.n,. <br /> DBA: 1 <br /> CROSSSTREET: G� <br /> PREMISE OWNER: PHONE: <br /> OWNERS AODRE5S: CITY: <br /> FACILITYCONTACT: S PHONE: <br /> RESPONSIBLE PARTY RP DBA: <br /> RP NAME: PHONE: <br /> RPADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,Spill,leak,fire,or abandoned/dumped material) <br /> ttl an -bed -FD WWA_y (Z <br /> 'gEauw� <br /> TIME RECEIVED: TIME OF ARRIVAL: TME OF DEPARTURE: LIM <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE Q TOO <br /> SJC EHD <br /> MATERIAL/CLASSIFICATION IWLMicu wwxKN <br /> IDENTIFICATION SPILLED? sm LIQUID §_1155 COMMENTS <br /> ELM) (DAD (N FTI <br /> oY Vm <br /> LEY DN <br /> oY nN <br /> oY oN <br /> oY DN <br /> DY DN <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESSi DATE MAIIED <br /> DATE PROP 65 COMPLETED: DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? O YES o NO <br /> ER BINDER COP IE : <br /> o SHORT-TERM ON TOP O NARRATIVE ❑ MAP 0 ANALYTICAL DATA D PROP 65/UAR a FILE CREATED <br /> o MANIFEST o REFERRALS o CLEAN UP REPORT o OTHER AGENCY REPORTS ❑ EXPOSURE RECORD o PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />