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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 /> EMERGENCY RESPONSE-RECORD <br /> DATE: SHORT TERM#: C000 Z% <br /> PREMISE <br /> ADDRESS: l9 c-a+'C.r.cl�f✓+A TA-- <br /> DBA: 1 <br /> r U' r+Y'v. <br /> A PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY (RP) N II <br /> DBA: f <br /> RP �a� 5 /'l 1/ PHONE: ��'T3S7� <br /> NAME: (1� <br /> RP ADDRESS: 245 Ll Av-a <br /> CITY: s OS <br /> RP CONTACT: L � /Z PHONE: A <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> T <br /> � 151'TIME <br /> RECEIVED: ARRIVAL:TIMEOF ' A�--. TIME OF DEPARTURE: 3o <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> -too <br /> i <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INYMvED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: `'� DATE MAILED: <br /> DATE COMPLETED....PROP 65: 7 c$ UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME,. ADDRESS PHONE . <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> SHORTJ O O NARRATIVE ! ANALYTICAL DATA. PR P 5 1 UAR <br /> EXPOSURE RECORD MAN IFE T ],CLEAN UP REFORT OTHER AGENCY REPORTS <br /> REFERRALS MAP I FILECREATED <br /> i <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />