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N. �;�,— SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ _ = 600 E Main Street Stockton - CA 95202 <br /> � (209) 468-3420- Fax:(209) 468-3433 • Web:www.sjgov.orglehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM#: <br /> PREMISE ADDRESS: CITY: <br /> DBA: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE; <br /> RESPONSIBLE PARTY(RP)DSA: <br /> RP NAME: PHONE; <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak,fire, or abandonedidum ed material <br /> TIME RECEIVED: 1� ro TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> PHYSICAL STATE; ❑ SOLID ❑ POWDER -,Cl GAS I ID ❑GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65: UAR:: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE {' <br /> 1 <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑YES ❑ NO <br /> E.R. BINDER COPIES: <br /> SHORT-TERM ON TOP I El NARRATIVE ANALYTICAL DATA PROP 65 1 LIAR <br /> EXPOSURE RECORD I M MANIFEST CLEANUP REPORT El OTHER AGENCY REPORTS <br /> REFERRALS I El MAP FILE CREATED <br /> Rev.08/16/10 Page 1 of 3 ER Record <br />