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SAN JOAQUIN COUNTY <br /> •�,• _ '�•Aon <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .. 600 E Main Street Stockton • CA 95202 <br /> ..�� w. :. <br /> (209) 468-3420 - Fax:(209) 464-0138 - Web:www.sjgov.org/ehd <br /> Q�IFOR� <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM#: 0000 32(O q <br /> PREMISE i/ n CITY: <br /> ADDRESS: T V <br /> DBA: <br /> PREMISE LJ�,yyy�n�,., /xl ���, PHONE: <br /> OWNER: <br /> OWNER'S ADDRESS: Q X720;✓0 CITY: U� <br /> FACILITY CONTACT. PHONE: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: r �l <br /> RP PHONE <br /> NAME: <br /> RP ADDRESS: CITY: <br /> RP CONTACT; C^�Yf � f/ /y PHONE /2/' �{3/ gC. ' � <br /> NATURE OF COMPLAINT G(explosion, spill, leak,fire, or abandoned/dumped material I <br /> TIME RECEIVED: /'.240747.m TIME OF ARRIVAL: D IYI TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> c oodr�' 4eWAL- <br /> �d Q/rIi•r`.�� � urs <br /> IDENTIFICATION OF MATERIAL(CHFMiCAUNvowED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65: a� ,:: UAR: <br /> PERSONS EXPOSED and/or INJU D <br /> NAME ADDRESS PHONE <br /> I <br /> i <br /> "PERSONAL. TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 651 UAR <br /> EXPOSURE RECORD PSMANIFEST CLEANUP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD ELECTRONIC VERSION Page 1 of 4 01/16/09 <br />