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Op4!�!N SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton• CA 95202 <br /> ` = (209)468-3420•F= (209)464-0138 • Web:www.sjgov.org/ehd <br /> 9��FoR� <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORTTERM#: COQO2-4,7I1 <br /> PREMISE <br /> ADDRESS: Z S3D i c� CITY. 5.b <br /> DBA: GZ a E <br /> PREMISE PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS: <br /> FACILITY PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) U <br /> DBA: V <br /> RP NAME: p /�� 6m PHONE: 62 2039 <br /> Rp <br /> ADDRESS: { O �Yv A k- CITY:RP <br /> CONTACT: (�`� Iv �(#,, PHONE: (002- / 7039 <br /> NATUREOF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> 1krfA <br /> 19(c IY U.fust 4)a4 I/dw fvr, <br /> TIME2� � TIME OF ARRIVAL: !d_ TiME� RE OF <br /> RECEIVED: Jv <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> . IDENTIFICATION OF MATERIAL(CHEMICAL mvoLvEn) <br /> SUBSTANCE SO POWDER GAS x LIQUID GRANULE <br /> FORM LID <br /> REFERRALSDATE <br /> TO: F MAILED: <br /> DATE COMPLETED....PROP UA <br /> 65: R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "FERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page I of 4 05/01/2007 <br />