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j \ SAN JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTHI)EPARTMENT <br /> 600 E Main Street Stockton•CA 95202 <br /> (209)468-3420•Fax:(209)464-0138• Web:wvvw.sjgov.ore./ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: 211 , SHORT TERM#: COOO .) <br /> PREMISE <br /> ADDRESS: CITY: i <br /> ,��` �;'�1 . l�-�C J�tcv-; �rU <br /> DBA: <br /> PREMISE �t ' � �' {_ PHONE: <br /> OWNER: <br /> OWNER'S ( CITY: <br /> ADDRESS: f • ` ;i ! r CA qc', l <br /> FACILITY ) I PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: �%I✓ 1 <br /> RPNAME: �`I'Cfv��-1, <br /> PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> y <br /> I t`` PHONE: <br /> CONTACT: 0 u' '-� r'" ` �_ '• <br /> NATURE OF COMPLAINT(explosion, spill,le k4 fire,or abandoned/dwn d material) <br /> S <br /> TIMEI TIME OF ARRIVAL: �j�i f�t3? TIME OF <br /> RECEIVED: L" ' DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> t, Fri j v. Flu f rjt % sM E <br /> �-3 �ir1T'L'vt.t,{=-t �rrlrrit'-�` t .i1-��;Iv }..-�f�r� ��.r` �(.fj .. `iff:`!•� <br /> IDE . CATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE ,' SO r POWDER GAS LIQUID GRANULE <br /> FORM LID i �'J <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP C'f 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 Page I of 4 05/01/2007 <br />