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oP" •" _ SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E Main Street Stockton ■ CA 95202 <br />(209) 468-3420 ■ Fax: (209) 464-0138 • Web: www.sjgov.org/ehd <br />AL)F ORS <br />EMERGENCY RESPONSE RECORD <br />DATE: <br />` ,Lj + p <br />SHORT TERM#: <br />COOO <br />PREMISE <br />ADDRESS: <br />CITY: <br />DBA: <br />PREMISE OWNER: <br />YES <br />PHONE: <br />NO <br />OWNER'S ADDRESS: <br />CITY: <br />FACILITY CONTACT: <br />�Q�( S�Q� <br />PHONE: <br />RESPONSIBLE PARTY (RP) <br />DBA: <br />RP <br />NAME: <br />PHONE: <br />RP ADDRESS: <br />CITY: <br />RP CONTACT: <br />PHONE: <br />NATURE OF COMPLAINT (explosion, spill, leak, fire, or abanaonea/aum ea ma[erim) l <br />I (ter 1-Q.i Ill 0,04 W� I Vd GIJ, ii �l J �1 �� ` <br />up 20 a� �ta� �l ��/ Tra-tyvw <br />TIME1 a TIME ARRIVAL: OF ' s TIME OF DEPARTURE: <br />RECEIVED: <br />Elm, <br />AGENCY <br />9 <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />YES <br />NO <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br />SUBSTANCE FORM I I SOLID I I POWDER GAS LIQUID GRANULE <br />REFERRALS TO: DATE MAILED: <br />__f� <br />DATE COMPLETED.... PROP 65: 1 I D UAR: <br />11i1�JVl\J L <br />NAME <br />ADDRESS <br />PHONE <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />YES <br />NO <br />ER RECORD MODIFIED Pagelof3 05/01/2007 <br />