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SAN JOAQUIN COUNTY <br /> � p P0. 1Y• �, <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: _ '7 09 SHORT TERM#: C000OS-7 <br /> PREMISE CITY: <br /> ADDRESS: 3km <br /> DBA: IPA M CO3 <br /> PREMISE es <br /> �! PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS: <br /> FACILITY PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) Ini P r7 4. <br /> DBA: �l a c <br /> RP NAME: r d-_ PHONE: <br /> ADDRESS: 33*7 N��'[V�. CITY: <br /> CRP <br /> ONTACT: �WIP� PHONE: �f WC ���21f7 <br /> NATURE OF COMP NT(eosion, spill, leak, fire,or abandoned/dumped material) l v <br /> TIMETIME OF ARRIVAL: Is TIME OF <br /> RECEIVED: � DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> m L^2g f-lm 490 3ys3 <br /> i <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM .LID <br /> REFERRALS DATE <br /> TO: k MAILED: <br /> I <br /> DATE COMPLETED....PROP / _ r�L't UA <br /> 65: t7 TV(3 R. <br /> i <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 /> I <br /> I <br />