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1 T <br /> r. i • <br /> o�q«" SAN JOAQUIN COUNTY -` Z <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton•CA 95202 ` <br /> ' (209)468-3420•Fax:(209)464-0138• Web:www.sjgov.orgr/ <br /> EMERGENCY RESPONSE RECORD <br /> DATE: A SHORT TERM#: CODD 1! <br /> PREMSE <br /> ADDRESS: l(o7-7 1 1 qjnd P-OAd CITY: <br /> DBA: <br /> OWNER EPREMIS �h PHONE; <br /> OWNER'S CITY: <br /> ADDRESS: G+'� <br /> FACILITY PHONE: �, r <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: [SV1Yi <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT ex losion, spill, leak, fire, or abandoned/dumped material) <br /> Sw4ytG OLCJ 6% W" <br /> C <br /> RECEIVED: ' W TIME OF ARRNAL: DE ARTURE- OF <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL mmmim mvmvm)� <br /> SUBSTANCELI <br /> RM LD <br /> FPOWDER GAS LIQUID OR FO <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED...,PROP UA <br /> 65: 1 R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDR 5 PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? I YES NO <br /> ER RECORD MODIFIED Page I of 05/01/2007 <br />