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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 /> AL�FOR� <br /> EMERGENCY RESPONSE RECORD <br /> DATE: _ {� ..�Q SHORT TERM#: C0003lvrg. <br /> PREMISE CITY: <br /> ADDRESS: CJ Z r �•h U .i t Dn`ve <br /> DBA: <br /> PREMISE ^• �7 /1 PHONE: <br /> OWNER: 1 <br /> ADDRESS: t�Z! t.+c.QrJa D» CITY: <br /> FACILITY //+ PHONE: �G C7 X 3�i <br /> CONTACT: d o� 1->Rds� 7��'t —C�5r2_-- IZ[7 <br /> RESPONSIBLE PARTY (RP) <br /> DBA: rX <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> rRp PHONE: <br /> CONTACT: 47 D 46v-w 14 <br /> X— <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire,or abandoned/dumped material) <br /> r -TO ��,tlo,�g �,Y�,. ,1.�.,�G .�G! C 3D 5~Uehs <br /> aPi�H�.Q -f�a l g•t:a 9�,//a�g wi fi� �,�� , <br /> TIME , TIME OF ARRIVAL: TIME OF <br /> RECEIVED: + ?j C7 .� w- DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> er- a IgG l l w u zo�i-9 -K.ro -z <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> -FORM <br /> LID POWDER GAS 'No LIQUID GRANULE <br /> REFERRALS DATE <br /> TO: h C MAILED: <br /> DATE COMPLETED....PROPUA <br /> 65: <br /> PERSONS EXPOSED and/or.INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD- COMPLETED? YES NO <br /> ER RECORD MODIFIED Page 1 of 4 05/01/2007 <br />