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0�4 SAN JOAQUIN COUNTY <br /> - c ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton ■ CA 95202 <br /> (209) 468-3420 • Fax: (209) 464-0138 ■ Web: www.sjgov.org/ehd <br /> �IFpR <br /> EMERGENCY RESPONSE RECORD <br /> DATE: i t - SHORT TERM#: 0000 <br /> PREMISE4 6✓ at <br /> rf Q CITY: <br /> ADDRESS: <br /> DBA: �I p <br /> PREMISE OWNER: [0� PHONE: <br /> OWNER'S ADDRESS: 4s620 c, Q,d CITY: <br /> LFA:C:ILi'I'Y CONTACT: 0 U PHONE: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: ff <br /> RP PHONE: <br /> NAME: <br /> RP ADDRESS: 6 3 - CITY: <br /> RP CONTACT: PHONE: a•'j 64LI ( �. <br /> NATURE OF COMPLAINT(explosion, spdl,leak,fire,or abandoned/dumped material <br /> *W, to ll t�rQ. . N�� �Z°16 i#+ro�e� an-En c,K GaIP r�C�:+"e& foo muck <br /> 6vqyve ofd al" wi+iii cow of- -mcg. s6m eAiei a s urm6te iA <br /> TIME TD4E <br /> RECEIVED: Dab ARRIVAL: OF TIME OF DEPARTURE: <br />` PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> MioUn (L �� Z <br /> IDENTIFICATION OF MATERIAL[CNEMiCAL]NVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUIII GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED.-PROP 65: lo UAR: <br /> PERSONS EXPOSED and/or INJUREb <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> eT SIiORT-TER OP NARRATIVE ANALYTICAL DAAR P 65 UAR <br /> SURE RFC (FEST CLEANUP kLbPORT I OTHER AGENCY RMRTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br /> p <br /> f <br />