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�oP° (y.co • SAN JOAQUIN COUNTY <br /> r i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton • CA 95202 <br /> (209) 468-3420 • Fax: (209) 464-0138 • Web: www.sj2ov.org/ehd • <br /> '9<I F`oR�; <br /> EMERGENCY RESPONSE RECORD <br /> DATE: �`�-aa-ll SHORT TERM#: C000 <br /> DAD S: Jdo� I aV O)'I Vr'i CTl•Y: i D <br /> DBA: aGI` yG .6 <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACIIITY CONTACT: -Cad PHONE: b 6 <br /> RESPONSIBLE PARTY (RP) <br /> DBA: 6 Ali l6Tv W <br /> -f'b PHONE: p�,3503�0 <br /> NAME: ll <br /> RP ADDRESS: ��ow I 61 'Moo, CITY: <br /> RP CONTACT: "LO PHONE: :),350,3-1 O <br /> NATURE OF COMPLAINT(explosion, spill,leak,fire,or abandoned/dumped material) <br /> W�d�� Tai[vre al- 9" C"vw-w l cw, e l ect ay ofTIME TIME I sul�rric cti�d �n <br /> RECEIVED: Ca''bO ARRNAL: OF I.�j(/ pYY1 TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 0CIA I --L --lv — <br /> 14AIllab 6-9 <br /> ^C <br /> IDENTIFICATION OF MATERIAL is mncv wvo wujTn44� — <br /> SUBSTANCE FORM SOLID POWDER I GAS LIQUID GRANULE <br /> REFERRALS TO; DATE MATLED: <br /> DATE COMPLETED....PROP 65: d�'as ' I I UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> .R.BINDER COPIES: <br /> HORT-TERM N T NARRATIVE AN IALDATA PROP 5/UAR <br /> EXPOS RE RD MANIFEST LAN UP RE T THER A ENCY REPORTS <br /> REFERRALS MAP FILECREAijev <br /> ER RECORD MODIFIED Page l of 05/01/2007 <br />