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o? 4U f r( c SAN JOAQUIN COUNTY <br />? ENVIRONMENTAL HEALTH DEPARTMENT <br />a <br />600 E Main Street Stockton ■ CA 95202 <br />(209) 468-3420 ■Fax: (209) 464-0138 ■Web: www.sjoy.or�lehd <br />gCjFp�ic� <br />EMERGENCY RESPONSE RECORD <br />DATE: 3 <br />SHORT TERM#: <br />CC700 3 7 Z,-?. <br />PREMISE <br />ADDRESS: I <br />Z <br />CITY: <br />RP <br />DBA: <br />CITY: <br />PREMISE <br />ADDRESS: <br />PHONE: <br />OWNER: <br />RP <br />/ <br />PHONE: <br />C/t( <br />OWNER'S <br />CONTACT: <br />CITY: <br />ADDRESS: <br />FACILITY <br />CONTACT: <br />�% <br />+ u <br />PHONE: <br />Z S i-% 6S"- <br />RESPONSIBLE PARTY (RP) <br />DBA: <br />L <br />1 �U <br />RP NAME: <br />PRONE: <br />RP <br />CITY: <br />ADDRESS: <br />RP <br />/ <br />PHONE: <br />C/t( <br />CONTACT: <br />NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br />t — D avcvus J l - Gds <br />TIMETIME OF ARRIVAL: / TIME OF <br />RECEIVED: <br />GU {� ` DEPARTURE: <br />,ti.... nr.�iir ♦m nnr. asr. <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br />SUBSTANCEso POWDER GAS X LIQUID GRANULE <br />iznuM LID <br />REFERRALSI I DATE <br />TO: MAILED: <br />DATE COMPLETED.... PROP !UA <br />65: _ R: <br />PERSONS EXPOSED and/or INJURED <br />"PERSONAL TOXIC SUBSTAIVCF. EXPOSURE RECORD" COMPLETED? YES NO <br />ER RECORD MODIFIED Page I of4 05/01/2007 <br />