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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..51 Ov_org/ehd <br /> 4�i�pRc1 <br /> EMERGENCY RESPONSE RECORD <br /> DATE: O SHORT TERM#: 0000 <br /> PREMISE ADDRESS: 1100 0 ' ►'''iii•F CITY: <br /> wa(m) <br /> DBA: i <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: PHONE: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material <br /> TIME RECEIVED: + TIME OF ARRIVAL: m TIME OF DEPARTURE: �LJ <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Dw"s obi � o _ old <br /> tirlcrn �` <br /> Y k <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALSTO: DATE MAILED: <br /> r' <br /> DATE COMPLETED....PROP 65: Y UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> Wrl <br /> 14 , <br /> "PERSONAL TOW SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65/LIAR <br /> EXPOSURE RECORD MANIFEST CLEANUP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page 1 of 4 10/21/09 <br />