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0 <br /> SAN JOAQUIN COUNTY <br /> •:_'' ENVIRONMENTAL HEALTH DEPARTMENT <br /> � `. <br /> 600 E Main Street Stockton■CA 95202 <br /> "" ,.. (209)468-3420■Fax: (209)464-0138 ■ Web.-Wwwsjgov.oreehd <br /> 4�fFQ.Rta <br /> EMERGENCY RESPONSE RECORD <br /> DATE: �� b D� SHORT TERM#: C00OZ61yo <br /> PREMISEn CITY: <br /> ADDRESS: <br /> DBA: <br /> PREMISE rPHONE:OWNER: <br /> OWNER'S ADDRESS: <br /> FACILITY , ` Y y 3 Q^ 9- <br /> CONTACT: !V <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/dumped material) <br /> Q V-a� .fid A z C4-X� <br /> ori "b " ( °(l-'-`ti" <br /> TIME TIME OF ARRIVAL: ^7 TIME OF <br /> RECEIVED: DEPARTURE: �(J <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS )C LIQUID GRANULE <br /> FORM LID <br /> REFERRALSDATE <br /> TO: E MAILED: <br /> DATE COMPLETED....PROP TC) 6 D p UA <br /> 65: D R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page 1 of 4 05/01/2007 <br />