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ul <br /> SAN JOAQUIN COUNTY <br /> 1 rt x ENVIRONMENTAL HEALTH DEPARTMENT <br /> N='; 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 • Fax: (209)468-3433 • Web:www.sjgov.org/ehd <br /> EMERGENCY .RESPONSE RECORD <br /> DATE: (��1� SHORT TERM#: <br /> PREMISE ADDRESS: I 10T4 <br /> CITY: C <br /> DBA: L,� <br /> 3 <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> 1 FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: PHONE: <br /> �3�_95 2- <br /> RP <br /> RP ADDRESS: i mwalwS GV& CITY: CA <br /> w' <br /> RP CONTACT: ] PHONE: <br /> NATURE OF COMPLAINT(explosion, <br /> spill, leak,fire, or abandoned/dumped material <br /> CAK Oe, S�W �'wk� 9 WAIAV 0 1 <br /> TIME RECEIVED: �.(l TIME OF ARRIVAL: l; TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> N,5 G m- �S ¢ <br /> 67 F— <br /> j i N RC. lq = <br /> a <br /> { IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> PHYSICAL STATE: ❑ SOLID ❑POWDER ❑GAS IQUID ❑GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65: '� ��'� UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP V NARRATIVE ANALYTICAL DATA 19 PROP 651 LIAR <br /> EXPOSURE RECORD MANIFEST CLEANUP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> Rev.04/19/12 Page 1 of 3 ER Record <br />