Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> . . ' 600 E Main Street Stockton - CA 95202 <br /> * a _w,::P• (209) 468-3420 • Fax;(209) 464-0138 • web.,www.sjgov.oralehd <br /> aft=oRa <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 1 SHORTTERM#: C000 �� I <br /> PREMISE ADDRESS: CIN: <br /> DBA: <br /> PREMISE OWNER: �NPHONE: <br /> OWNER'S ADDRESS: �•jW ( G �✓r J�yt CITY: <br /> FACILITY CONTACT: J PHONE: <br /> RESPONSIBLE PARTY{RP}DBA: !V <br /> RP NAME: S /� ��W'4� PHONE: "[t� IGW 3SIO dam/ 6� <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> I <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> R95,5r ( Vtiti o-11(e 6" Canek rql�ul dpi `3�1- i <br /> I 94I <br /> TIME RECEIVED: b TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> ' 3a <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS KI LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65: aL: p�! LIAR: <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 NARRATIVE ANALYTICAL DATA PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEANUP REPORT I OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page 1 of 4 10/21/09 <br />