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SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> (209)468-3420 • Fax.(209)464-0138 • Web:www.sigov.org/ehd <br /> tiFokN� <br /> EMERGENCY RESPONSE RECORD (� <br /> DATE: SHORTTERM#: COOO <br /> PREMISEADDRESS: I!K01 yd sr CITY: <br /> DBA: <br /> PREMISE OWNER: N�j r PHONE: ..,^,JJ� <br /> OWNER'S ADDRESS: M Dr- CIN: f�)"TK <br /> FACIUTY CONTACT: V� 6ell PHONE: o <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: PHONE: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> A->Jvasc ob /2 a&wio l vy,* <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> ✓in /IL✓ b - a 23/ sfrfif <br /> IDENTIFICATION OF MATERIAL(CLEMIUL) V W DI <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: 1� DATE MAILED: <br /> DATE COMPLETED....PROP 65: ,c 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/LIAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page 1 Of 4 10/21/09 <br />