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>opqu IN•C, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> + i• +?�� <br /> 4 � : 600 E Main Street Stockton■CA 95202 <br /> (209)468-3420■Fax:(209)464-0138 • Web:www.sjgov.o g ehd <br /> FOR� <br /> EMERGENCY RESPONSE RECORD <br /> DATE: . Z3 Oq SHORT TERM#: COOO. . al I.S <br /> PREMISEJ� ( � , CrrY: T (.� i J . <br /> ADDRESS: J J �/�-J(J)A) <br /> DBA: e6t5-�(Y <br /> PREMISE PHONE: <br /> OWNER: <br /> CITY. <br /> ADDRESS: J 2/ ' <br /> FACILITY �,/� (_ /J L� PHONE: �LCf, �Q i <br /> CONTACT: l Y 1 G(IVIL 1/�/LL q- <br /> CONTACT: <br /> PARTY (RP) <br /> DBA: L v } o <br /> RP NAME: PHONE: <br /> RP ,I <br /> ADDRESS: I �1 (, �J✓ CITY: C m G��- i <br /> PHONE: <br /> CONTACT: `�l W V il.. YO LC,f� j <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> Ilwy t-Ir xh-4� di" tca-" 44� #u rav\,d <br /> A-C, I <br /> i <br /> TIME <br /> n i <br /> RECEIVED: 16- U d TIME OF ARRIVAL: l P TIME OF <br /> I/. (Dooml DEPARTURE: <br /> PERSONS AT SCENE <br /> �n NAME AGENCY PHONE TOA TOD <br /> Y 1 2AL L <br /> I <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM I LID <br /> REFERRALS F /L�]®G) DATE <br /> TO: [ r 1 MAILED: <br /> DATE COMPLETED....PROP */-Z3/0 �j 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 MODIFIED Pagel of 4 05/01/2007 <br />