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SAN JOAQUIN COUNTY <br /> 2' .2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> N' { 600 E Main Street Stockton • CA 95202 <br /> (209) 468-3420 • Fax: (209) 464-0138 • Web: www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM#: CO00 <br /> PREMISEr„ Cly. <br /> ADDRESS: Y/ <br /> DBA: <br /> PREMISE OWNER; ` 6rZr --fY- PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: Lc-z3_ <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RPl+ PHONE: <br /> NAME: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> L,,CA* -- <br /> TI TIME <br /> RECEIVED: <br /> ARRIVAL: <br /> OF TIME OF DEPARTURE: ���.9►�n <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> h <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) i <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65 UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> i <br /> i <br /> i <br /> t <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65!UAR <br /> EXPOSURE RECORD 17MANIFEST CLEANUP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />