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�PpUIN • SAN JOAQUIN COUNTY , <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> _a <br /> N _ 600 E Main Street Stockton•CA 95202 <br /> (209)468-3420•Fax:(209)464-0138• Web:www.sieov.ore/ehd <br /> 9Git ORN`P <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Z/y SHORT TERM#: COOO Z� 1l / <br /> ADDRPREMESS: D�(? CITY: <br /> DBA: <br /> PREMISE PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS: <br /> FACILITY PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: GiS stn ✓ -RPNAME: 1�r O Irl^^ PHONE: C� Z457 <br /> ADDRESS: zoo / v�%vl L/r1V� CITY: /'L 520 10 <br /> RP PHONE: <br /> CONTACT: <br /> NATURE/OF COMPLAINT(explosion, sp illi,leak, fire/,for abandoned/dumped material <br /> or Ae- (f.4TIME <br /> TIME <br /> RECEIVED: / D a� TIME OF ARRIVAL: // s!+^— DEPARTURE: OF <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL�cHEwcn�arvoLvaol <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM LID <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP UA <br /> 65: D R: <br /> PERSONS EXPOSED and/or INJURE <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page I of 4 05/01/2007 <br />