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SAN JOAQUIN COUNTY � <br /> u <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ H 600 E Main Street Stockton + CA 95202 <br /> (209) 468-3420 • Fax: (209) 464-0138 ■ Web: www.sigov.org/ehd <br /> PO <br /> EMERGENC ESPO S RECORD. <br /> DAZE: t 0 SHORT TERM#: X000 3 r'ZQ CIT <br /> PREMISE / �} (} CITY L a f <br /> ADDRESS: <br /> DBA: �'R ►,.— ��� <br /> PREMISE OWNER: ]�. �i lo-� �� PHONE: <br /> OWNER'S ADDRESS: x, Ir CITY: G q f rty r-j Com. 3 <br /> FACILITY CONTACT: p.�aG PHONE: 2-09 <br /> RESPONSIBLI; PARTY (RP) si t r_ <br /> f [.tea bN <br /> RP <br /> NAME: PHONE: d q ewj-g <br /> RP ADDRESS: -7 M, CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion,spill. leak,fire,or abandoned/dumped mattee+rial �+ (, <br /> Z-z' O 650 <br /> TIME f p�p'— TIME OF �' S P'-` TIME OF DEPARTURE: <br /> RECEIVED: ARRIVAL: Z Z-3-0'1 -J <br /> PERSONS AT SCENE <br /> NAME AGENCY <br /> ii PHONE TOA T D <br /> a t •3 0 <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID T—TPOWDER PAS L[QUID GRANULE. <br /> REFERRALS TO: a T5` G U IZ L.)Q C DATE MAILED: 1 Z Y u <br /> DATE COMPLETED.-PROP 65: 0-a- UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> AME ADDRESS PHO <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES \ NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERAMTM I A PR R <br /> MANWEST ULEAN UP REMRT OTHER AGENUY REPO <br /> ER MAP FILE CREATED <br /> ER RECORD MODIFIED Page iDf3 05/01/2007 <br />