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o�ny!(y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton • CA 95202-3029 <br /> (209) 468-3420 • Fax: (209) 464-0138 • Web: www.sjgov.org/ehd <br /> �rFO a <br /> EMERGENCY RESPONSE RECORD <br /> DATE: I SHORT TERMN: CO00 <br /> PREMISE ADDRESS: �� 3?3� W CITY: <br /> DBA: {X <br /> PREMISE OWNER: PHONE: � ', <br /> OWNER'S ADDRESS: 5 �V,, 't aA W-L CITY: si �M�/lov-1- <br /> FACILITY CONTACT: I O CjI1 l-I tih&k_ PHONE: &7;4 - b 3 33 <br /> RESPONSIBLE PARTY(RP)DBA: l rA e C- <br /> RP <br /> RP NAME: I PHONE: <br /> RP ADDRESS: -F---;C740 N M" , r CITY: Ai ad rKo <br /> RP CONTACT: PHONE: �U <br /> NATURE OF COMPLAINT ex losion spill,leak fire,or abandoned/dumped material <br /> '1 <br /> TIME RECEIVED: R: IoC4 W\ I TIME OF ARRIVAL: !i]i 3 d TIME OF DEPARTURE: I I l j U <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> C N�Pit_ W- 04 swomOr allterce axteR.w <br /> . Sus lo267"p1T dla cr"h.e •sw� <br /> IDENTIFICATION OF MATERIAL tarenacamv«.vm� <br /> SUBSTANCE FORM SOLID POWDER I GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65: UAR: <br /> PERSONS EXPOSED and/or INSURED <br /> NAM ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT OTHER AGENCY REPORTS <br /> REFERRALS X1 MAP I I FILE CREATED <br /> ER RECORD MODIFIED Page l of 02-05-2007 <br />