Laserfiche WebLink
o.P°'`' N •.c 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.sigov.org/ehd <br />EMERGENCY RESPONSE RECORD <br />DATE: <br />1 J <br />1 O <br />SHORT TERMLY: <br />COOO v` <br />PREMISEn <br />ADDRESS: <br />- 0 <br />`� f`-Y/j <br />CITY: <br />CITY: <br />DBA: <br />-Ilk 4Q_� <br />PREMISE OWNER: <br />PHONE: <br />PHONE: <br />YES <br />OWNER'S ADDRESS: <br />NO <br />CITY: <br />FACILITY CONTACT: <br />qb <br />PHONE: <br />RESPONSIBLE PARTY (RP) <br />DBA: <br />�` ^ � I�� <br />�" ) Q� <br />RP <br />NAME: <br />• <br />PHONE: <br />DATE COMPLETED.... PROP 65:7l <br />RP ADDRESS: <br />UAR: <br />CITY: <br />RP CONTACT: <br />PHONE: <br />NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br />l�� ra,�l ��,r-�►l�d 2o,c�0 ,fir <br />qktl�l <br />TIME j /Lim TIME OF TIME OF DEPARTURE: <br />RECEIVED: I L- v V ARRIVAL: s <br />PF.RSONS AT SCF.NF <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br />SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br />REFERRALS TO: <br />I <br />' 4 <br />• <br />�� <br />DATE COMPLETED.... PROP 65:7l <br />D <br />UAR: <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />YES <br />NO <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br />SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br />REFERRALS TO: <br />I <br />I IDATE <br />MAILED: <br />DATE COMPLETED.... PROP 65:7l <br />D <br />UAR: <br />PERSONS EXPOSED and/or INJURED <br />NAME <br />ADDRESS <br />PHONE <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />YES <br />NO <br />E. R. BINDER COPIES: <br />SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65 / UAR <br />EXPOSURE RECORD MANIFEST CLEANUP REPORT OTHER AGENCY REPORT <br />REFERRALS MAP FILE CREATED <br />ER RECORD MODIFIED Pagelof3 05/01/2007 <br />