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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 /> A(j�Q�ia <br /> EMERGENCY RESPONSE RECORD <br /> DATE: O� ``. SHORT TERM#: C000 <br /> ADR DRESE SS: �o°g I �'av/ o t ve CITY: <br /> DBA: I spaaq G a <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILPPY CONTACT: 4 up, Tdd-d PHONE: v a <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP 1 �6 PHONE: a_350 31`1 <br /> NAME: 1 C <br /> RP ADDRESS: �p <br /> _,D CITY:crrY: lf-&.�f-uA <br /> RP CONTACT: ko -rD Go, PHONE: 3-3C50�3 1 b <br /> NATURE <br /> 4 OF COMPLAINT(explosion, ill, leak, fire,or abandoned/dumped material) r R <br /> TIME �aap TIME OF TIME OF DEPARTURE: <br /> RECEIVED: ARRIVAL: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> -14A III MA -C 2 L10 <br /> Ll Wlko <br /> IDENTIFICATION OF MATERIAL(CRMCALINvoi. , — <br /> SUBSTANCE FORM SOLID POWDER GAS LIQum GRANULE <br /> REFERRALS TO: I DATE MAILED: <br /> DATE COMPLETED....PROP 65UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> .R.BINDER COPIES: <br /> SHOrT_-TERM ON TOP I NARRATIVE I I ANALYTICAL DATA PROP 65 1 UAR <br /> EXPOSURE RECORD 1,j I MANIFEST CLEANUP EPORT OTHER AGENCY REPORTS <br /> REFERRALS I MAP FILE REA ED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />