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SAN JOAQUIN COUNTY <br /> z�:� �r�� "• ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' 600 E Main Street Stockton • CA 95202 A)VIVEA <br /> (209) 4 68-34 20 - Fax: (209) 464-0136 ■ Web: www._sjgov.org/ehd UJ <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Z� V SHORT TERM#: C000 2-b 7, <br /> PREMISE 2 CITY: <br /> ADDRESS: <br /> DBA: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: a- <br /> RESPONSIBLE PARTY (RP) , <br /> DBA: A- <br /> RP PHONE: <br /> NAME: l'br-. h p 15 s� 7 1 <br /> RP ADDRESS: CITY: <br /> RP CONTACT: j7 PHONE: 5-557_65-27 <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIMEn ,, TIME OF TIME OF DEPARTURE: <br /> RECEIVED: /,r�'1 ARRIVAL: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL IWvoLVEDr <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED.-PROP 65: UAR: <br /> PERSONS EXPOSED and/or IN.IU <br /> NAME ADDRESS PHONE <br /> a <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> r E. R.BINDER COPIES: j <br /> H R -TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65 1 UAR <br /> EXPOSURE RECORD MANIFEST I CLEAN UP REPORT OTHER AGENCY REPORTS <br /> ��j <br /> REFERRALS I>d MAP I I FILE CREATED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br /> i <br />