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SAN JOAQUIN COUNTY <br /> z7 ` � ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton■ CA 95202 <br /> ' (209)468-3420 f Fax: (209)464-0138 • Web:www.sieov.orQ/ehd <br /> 9LJ=p.Rt: <br /> EMERGENCY RESPONSE RECORD <br /> DATE: �� ^� �� SHORT TERM#: COOO j7,K L <br /> PREMISE ,rte !_ CITY: <br /> ADDRESS: `F ' C—m►lJWive- C, <br /> DBA: <br /> PREMISE PHONE: <br /> OWNER: S Z- <br /> OWNER'S r� "I CITY: I <br /> ADDRESS: <br /> FACILITY �� PHONE: <br /> CONTACT: <br /> 5 <br /> RESPONSIBLE PARTY (RP). <br /> DBA: <br /> RP NAME: PHONE: <br /> Rp <br /> rCRP <br /> DDRESS: '� <br /> CITY: <br /> PHONE: <br /> ONTACT: <br /> NATURE OF COMPLAINT(explosion, s ill, leafs,fire, or abandoned/dumped material) ' <br /> ]3 D 1a d ckTIME <br /> r <br /> RECEIVED: - O TIME OF ARRIVAL: I p PARTURE:ME OF �1 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> i <br /> IDENTIFICATION OF MATERIAL(CBEMICAL INVOWED) <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM LID <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP UA <br /> 65: R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page I of 4 05/01/2007 <br />