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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton• CA 95202 <br /> (209)468-3420• Fax:(209)464-0138 • Web:wcvw.sjeov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 1 <] -2Z l 1 SHORT TERM#: C0002j Zt{ v <br /> PREMISE <br /> ADDRESS: `( D� L l A/WL4y-J s CITY: s <br /> DBA:PREMIS <br /> OWNER: <br /> PHONE: 2�c� _ 6 v b3 0 6 <br /> OWNER'S CITY: 1_ 1 <br /> ADDRESS: taNvLC,,dS F S Iv�7Y�'1 <br /> FACILITY PHONE: 1 <br /> CONTACT: V-L Y1 7'p 9J U 6 3 (� <br /> RESPONSIBLE PARTY (RP) �,wt C <br /> DBA: (j/ (— <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire,or abandoned/dumped material) <br /> 900 0 <br /> TIME TIME OF ARRIVAL: TIME OF <br /> RECEIVED: DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> N �) <br /> 4o G <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM LID <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP i O Z I ( UA <br /> 65: R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page l of 4 05/01/2007 <br />