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oPQ " SAN JOAQUIN COUNTY <br /> u�G <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton - CA 95202 <br /> (209) 468-3420 - Fax: (209) 464-0138 - Web:www.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM#: COOD,0r?Q- 5 <br /> PREMISE ,q j L CITY: <br /> ADDRESS: <br /> DBA: / /--ly-y, ` <br /> l i <br /> O <br /> PREMISE ��/ G. Q.,�at PHONE: <br /> OWNER: <br /> OWNER'S ADDRESS: PLO low CITY: r�a <br /> G <br /> FACILITY CONTACT: PHONE: 01 {J SLY"r -00-7 <br /> RESPONSIBLE PARTY (RP) I( � <br /> DBA: V Glib <br /> RP PHONE <br /> NAME: _. <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE <br /> C <br /> NATURE OF COMPLAINT(explosion,spill, leak,fire,or abandoned/dumped material <br /> TIME RECEIVED: D TIME OF ARRIVAL: Q/r� TIME OF DEPARTURE: �I <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> C <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) le <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65: UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA 14 PROP 651 UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT I OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD ELECTRONIC VERSION Page 1 of 4 01/16/09 i <br />