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-.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.sjgov.orv,/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: (7"Z S J SHORT TERM#: COOO 3 d 5' <br /> PREMISE / / CITY: <br /> ADDRESS: C;",--., <br /> I-.J•,SG�% Tom-- �� u14 <br /> DBA: �H5 <br /> PREMISE C L PHONE: <br /> OWNER:OWNER'S <br /> ADDRESS: t'� cam. ��iC Z4 S CITY: / C_ <br /> FACILITY <br /> FACILITY 1 4'G, �aG� ne, PHONE: z0 — �� C.ZT�a <br /> CONTACT: <br /> DBA:RESPONSIBLE PARTY (RP) FT, C_j, <br /> RP NAME: '�{� C.J�e•� � f{- PHONE: — 44L <br /> CITY: <br /> ADDRESS:RP <br /> CONTACT: �a 141 p PHONE: s j G Z 3 l �7J <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> 5o ems.//--5 -:.. � <br /> -744, <br /> TIME / TIME OF ARRIVAL: 3 �s TIME OF , <br /> RECEIVED: I '30 DEPARTURE: �s <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> �46- y�oI- <br /> x-66 -4q0 <br /> IDENTIFICATION OF MATERIAL CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS LIQUID GRANULE <br /> FORM LID I I ��l <br /> REFERRALSDATE <br /> TO: — 1•c l•.- - i✓ ( MAILED: -7- /- 0 <br /> DATE COMPLETED....PROP I UA <br /> 65: 0,9 R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> ✓�.-� <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page l of 4 05/01/2007 <br />