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o.?aUIN•.c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> u): { 600 E Main Street Stockton•CA 95202 <br /> (209)468-3420•Fax:(209)464-0138 • Web:www.sLQov.orl,/ehd <br /> ��/FORS <br /> EMERGENCY RESPONSE RECORD <br /> DATE: I Z SHORT TERM#: COOO 34-c- c1 <br /> PREMISE �/�,"� II � �/ / CITY: �� <br /> ADDRESS: U'`f �' lA Jlil ILLI <br /> DBA: LA (DS 1 P (� ei�V� <br /> PREMISE PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS: <br /> FACILITY <br /> CONTACT: <br /> K Vo (�,�/�(� PHONE: <br /> RESPONSIBLE PARTY (RP) 7S <br /> DBA: U <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RPV-0 <br /> I PHONE: <br /> CONTACT: kxj-v v O A L <br /> NATURE OF COMPLAINT(explosion, spill,leak, fire,or abandoned/dumped material) <br /> �- GV►'t�ir�'�-c- 2✓� � � C-E� [�a� 5,/.� C Q/�D�'Y1�c <br /> Ff -) 3TIME . <br /> RECEIVED: TIME OF ARRIVAL: ' �D TIME OF 4 . 0 <br /> l C Da ti v� DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM I I LID <br /> REFERRALS DATE <br /> TO: I MAILED: <br /> DATE COMPLETED....PRO;F S I Z I ' 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 Paget of4 05/01/2007 <br />