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o.Pa"'••"••.c SAN .JOAQUIN COUNTY <br /> FILIE Copy <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton•CA 95202 <br /> •'`t ' (209)468-3420•Fax:(209)464-0138 • Web:www.sigov.oreehd <br /> Q�iFORa <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM#: C0002 LP <br /> PREMISE CITY: <br /> ADDRESS: l a ,�a ?7►.i <br /> DBA: <br /> PREMISE �� �— PHONE: <br /> OWNER: 511STI L��. <br /> �`T <br /> OWNER'S CITY: <br /> ADDRESS: J �- G1�.- 7 r� <br /> FACILITY PHONE: <br /> CONTACT: Arli-l- H 4H41 <br /> RESPONSIBLE PARTY (RP) 7-7 <br /> DBA: a <br /> RP NAME: p1...- ,R�y PHONE: L <br /> RP CITY: �T= 503 <br /> ADDRESS: c� a/►'Is s •l�••K <br /> RP L G /Wf A r PHONE: -5W- 67i' <br /> i �c� <br /> CONTACT: 6 �� �� -3 <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material <br /> TIME / TIME OF ARRIVAL: TIME OF <br /> RECEIVED: ! wa.- DEPARTURE: <br /> Kr <br /> PERSONS AT SCENE <br /> NAME A ENCY PHONE TOA TOD <br /> r�t'k CQ— ?13210 <br /> z0q— 10 <br /> „ 3i (,y o f .— 11-3-0 <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCESO POWDER GAS 19LIQUID GRANULE <br /> FORM LID <br /> 17 <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP UA <br /> 65: ,NVQ 10 R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRES PH <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES X NO <br /> ER RECORD MODIFIED Page I of4 05/0112007 <br />