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SAN JOA UIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E Main Street Stockton - CA 95202 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www._S29CC org/ehd <br />EMERGENCY RESPONSE RECORD <br />DATE: <br />AGENCY <br />SHORT TERM#: <br />COOO <br />PREMISE(� <br />ADDRESS: <br />��^^ �! <br />CITY: <br />2„ , <br />2 ,. <br />DBA: <br />O �, S <br />PREMISE OWNER: <br />SqK� S�� <br />PHONE: <br />OWNER'S ADDRESS: <br />Lj <br />CITY: <br />FACILITY CONTACT: <br />PHONE: <br />RESPONSIBLE PARTY (RP) <br />DBA: <br />�^ <br />RP <br />NAME: <br />�^ <br />PHONE: <br />RP ADDRESS: <br />CITY: <br />RP CONTACT: <br />PHONE: <br />NATURE OF COMPLAINT (explosion spill leak fire or abandoned/dumped material) p <br />li F G � TO "T �-�- 5 9� �-e �G-�-' �"rrz.V� ..� r.�,.•.c � GY'D SSvS ���'��Yy.a- S, <br />TIME TIME OFTIME OF DEPARTURE: <br />�' t <br />RECEIVED: �oy a�� ARRIVAL: 2 v��o ^ <br />PERSONS AT SCENE <br />NAME <br />AGENCY <br />PHONE <br />TOA TOD <br />FM <br />15-505-21 <br />2„ , <br />2 ,. <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />YES <br />1xiNO <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) N 14 <br />SUBSTANCE FORM I I SOLID I I POWDER GAS I LIQUID GRANULE <br />REFERRALS TO: __ II DATE MAILED: <br />DATE COMPLETED.... PROP 65: /V UAR: <br />PERSONS EXPOSED and/or INJURED <br />NAME <br />ADDRESS <br />PHONE <br />V <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />YES <br />1xiNO <br />E. R. BINDER COPIES: <br />SHORT-TERM ON TOP NARRATIVE I ANALYTICAL DATA PROP 65 / UAR <br />EXPOSURE RECORD MANIFEST CLEAN UP REPORT THER AGENCY REPORTS <br />REFERRALS MAP FILE CREATED <br />ER RECORD MODIFIED Pagelof3 05/01/2007 <br />5/0 -- <br />