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r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton• CA 95202 <br /> (209)468-3420• Fax:(209)464-0138 • Web:www.sjgov.ortJehd <br /> �TFOR <br /> EMERGENCY RESPONSE RECORD <br /> DATE: J`i SHORT TERM#: COOO � <br /> PREMISE CITY: <br /> ADDRESS: l <br /> DBA: <br /> PREMISE TP <br /> PHONE: <br /> OWNER: �yz, <br /> OWNER'S ) CITY: <br /> ADDRESS: P I( v ams <br /> FACILITY PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP NAME: e{hy,� O f'�►IGc..-tea PHONE: OZ- <br /> RP CITY: <br /> ADDRESS: Lt G))tr�LCA <br /> CONTACT: 1,Ce PHONE: 6 ��_ / ?2 V or <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) O <br /> TIME IS TIME OF ARRIVAL: lQ��! TIME OF <br /> DEPARTURE: <br /> RECEIVED: <br /> PERSONS AT SCENE <br /> NAME AGENCY PH NE TOA TOD <br /> �"tM1li !� <br /> i Sas—Dµ75 <br /> G S r <br /> IDENTIFICATION OF MATERIAL ICHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM L[D <br /> REFERRALS ht DATE A <br /> TO: MAILED: <br /> DATE COMPLETED....PROP /Z r� v�-/ UA <br /> 65: ( 7 b R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> u� <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page I of 4 05/01/2007 <br />