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SAN JOAQUIN COUNTY <br /> p� °;� ••� ENVIRONMENTAL HEALTH DEPARTMENT <br /> "E 600 E Main Street Stockton • CA 95202 <br /> (209)468-3420- Fax: (209) 468-3433 • Web:www.siclov.org/ehd <br /> 9L/FOQ� <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 4& SHORTTERM#: Gp�p'3 <br /> PREMISEADDRESS: 0 CITY: S <br /> DBA: <br /> PHONE: <br /> PREMISE OWNER: <br /> CITY: <br /> OWNER'S ADDRESS: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: �nP <br /> PHONE: <br /> RP NAME: <br /> CITY: <br /> RP ADDRESS: <br /> PHONE: <br /> RP CONTACT: <br /> NATURE OF COMPLAINT(explosion, spill, leak,fire, or abandoned/dum ed material)L <br /> I O'D 644,� &I <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE _ <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CMEAIICP lwmvml) <br /> PHYSICAL STATE: ❑ SOLID ❑ POWDER ❑GAS IWLIQUIU ❑GRANULE <br /> DATE MAILED: <br /> REFERRALS TO: <br /> DATE COMPLETED: PROP 65: <br /> UAR: <br /> PERSONS EXPOSED and/or INJURED PHONE <br /> NAME ADDRESS <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑YES ❑ NO <br /> E. R.BINDER COPIES: <br /> Lood <br /> NARRATIVE ANALYTICAL DATA PROP 651 UAR <br /> SHORT-TERM ON TOP CLEANUP REPORT OTHER AGENCY REPORTS <br /> EXPOSURE RECORD MANIFEST <br /> I Fl REFERRALS MAP FILE CREATED <br /> Rev.08116/10 <br /> Page 1 of 3 ER Record <br />