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M <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton■ CA 95202 <br /> "y (209)468-3420■Fax:(209)464-0138 ■ Web:www.siRov.orit/ehd <br /> F ORS <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 10 11-5t D9 SHORT TERM#: CO[[OO <br /> PREMISE <br /> ADDRESS: 64-2 S N Pot CITY: <br /> DBA: 5!!* <br /> !Lf' I <br /> PREMISE PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS:FACILITY f / <br /> CONTACT: V w" a�0 G7�G�L PHONE: (XV-0 4L7-Z — f&O p <br /> S <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/duln ed material) <br /> TIMETIME OF ARRIVAL: TIME OF <br /> RECEIVED: to- s-�^ t 30DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS 1C LIQUID GRANULE <br /> FORM LID <br /> REFERRALS DATE <br /> TO: I MAILED: <br /> DATE COMPLETED....PROP 10/16 lV y 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 MODIFIFD Page 1 of 4 05/01/2007 <br />