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6 <br /> oPqu,Irr c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton•CA 95202 <br /> (209)468-3420-Fax:(209)464-0138 • Web:w,,w.sjtov.ory-/ehd <br /> �L�FORCI <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Z1 ) SHORTTERM#: C000.3Lp4-CL <br /> PREMISE ` r CITY: L <br /> ADDRESS: d hlW L� /Z S I I13� <br /> DBA: 14!4 t <br /> PREMISE PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS: <br /> FACILITY \\ PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) ��/!( S'c�M l G>(L�-✓ <br /> DBA: <br /> RP NAME: PHONE: ,N ,/ <br /> RP j 14-3 A / n t/ CITY: �/J� C -ZC- <br /> ADDRESS: Kl �1 <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire,or abandoned/dumped material) <br /> 4w) <br /> TIME ) , TIME OF ARRIVAL: s•(x) TIME <br /> TURE: OF 6 , <br /> RECEIVED: / O <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS 1xl LIQUID GRANULE <br /> FORM LID <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP Z 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 of4 05/01/2007 <br />