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0 <br /> 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.oreehd <br /> 4�!•ppRTa <br /> EMERGENCY RESPONSE RECORD <br /> DATE: �� D$ SHORT TERM#: c000zqvo <br /> PREMISEn CITY: <br /> ADDRESS: ZS�T O S f" <br /> DBA: <br /> PREMISE PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS: <br /> FACILITY y PHONE: �-7 <br /> CONTACT: IV <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT(explosion, spill,leak, fire,or abandoned/dumped material) <br /> AMU4 V-aUve— d A,,,d l,¢"A A 2 �cc.vv Cin c <br /> oY, •b - rn,t" ( °(F'-" a,r- ) <br /> TIME TIME OF ARRIVAL: TIME OF µ, <br /> RECEIVED: LV►v` G' DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL{CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS )C LIQUID GRANULE <br /> FORM LID <br /> REFERRALSDATE <br /> TO: E MAILED: <br /> DATE COMPLETED....PROP Io ] Op UA <br /> 65: I D R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? I I YES NO <br /> ER RECORD MODIFIED Page 1 of 4 05/01/2007 <br />