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3 <br /> I <br /> SAN JOAQUIN COUNTY <br /> 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 /> 4Zrr�oR� <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 2 Z7 d7 SHORT TERM#: C0oo2.-7{ q_ <br /> PREMISE / CITY: �( <br /> ADDRESS: <br /> DBA: <br /> PREMISE OWNER: ' /j ' � PHONE: <br /> OWNER'S ADDRESS: CITY: (�y�. <br /> FACILITY CONTACT: G �' PHONE: qrj _ ,Ss, 9459 <br /> RESPONSIBLE PARTY (RP) <br /> DBA: LA 1�RP <br /> NAME: l�/�4�CX �C�+..'� PHONE: 2o9^ OS� �Z�-✓�' <br /> ' RP ADDRESS: (� '�' CITY: ,,-AC r car <br /> i <br /> ! RP CONTACT: PHONE: N p <br /> NATURE OF COMPLAINT(exp Osion, spill, leak, fire, or abandoned/dum d material) <br /> r�r <br /> � A Z 7 � boa f <br /> .�+^ rte, <br /> -�/ - -f�,�- • -� AAs � sL�� <br /> ,I <br /> 4 TIME FAIRMRI�AL: <br /> OF aC` TIME OF DEPARTURE: ��RECEIVED: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA :TOD <br /> G ✓�. � r ' <br /> r <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> �- E <br /> REFERRALS TO: [t,�(�� S{�1�ie. I`/' •f' G _ DATE MAILED: <br /> DATE COMPLETED....PROP 65: �-7 D 7 UAR: <br /> PERSONS EXPOSED and/or INJURED r <br /> NAME ADDRESS PHONE E <br /> i <br /> h <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES X NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65 I UAR <br /> EXPOSURE RECORD MANIFEST CLEANUP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page I of 05/01/2007 <br />