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J <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: wNvw.sIggv.org/ehd <br />EMERGENCY RESPONSE RECORD <br />DATE: <br />EADDRESS: <br />S <br />SHORT TERM: <br />C000 <br />PREMISE <br />ADDRESS: REMISE <br />SS. <br />TOA <br />CITY: <br />DBA: <br />7 <br />PREMISE <br />OWNER: <br />7 7--- <br />PHONE:4j- <br />OWNER'S <br />ADDRESS: <br />CITY: <br />FACILITY <br />,CONTACT: <br />PHONE: <br />.......... <br />RESPONSIBLE PARTY (RP) <br />S <br />DBA: <br />AGENCY <br />RP NAME: <br />TOA <br />PHONE: <br />RP <br />D-rl- <br />CITY: <br />7 7--- <br />ADDRESS: <br />[RP <br />PHONE: <br />CONTACT: <br />1,-4 <br />INA I UK -h Ur UUMrLAII141 (explosion, spill, leak, fire, or abandonedh <br />C <br />rXI <br />(4, <br />C <br />r- L7 <br />TIME TIME OF ARRIVAL: <br />RECEIVED; tii <br />PPQ4Z111%T4Z Ar 4Z(T7XTC <br />lox '%tj4x, <br />TIME <br />DEPARTURE: <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br />SUBSTANCE so I <br />FORM F I LID I POWDER — 77 GAS LIQUID GRANULE <br />REFERRALS <br />NAM -E-- <br />—71T, <br />DATE <br />AGENCY <br />PHONE <br />TOA <br />TOD <br />DATE COMPLETBD.�,.PROP <br />D-rl- <br />7',, c <br />7 7--- <br />65: <br />1,-4 <br />v\ <br />I <br />c <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br />SUBSTANCE so I <br />FORM F I LID I POWDER — 77 GAS LIQUID GRANULE <br />REFERRALS <br />I <br />DATE <br />TO: <br />MAILED: <br />DATE COMPLETBD.�,.PROP <br />YES <br />65: <br />PFR�qONS P.3(P0.QPD 5%nd/nr INITIRPr) <br />NAME ADDRESS <br />PHONE <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD- COMPLETED? <br />YES <br />I NO <br />ER RECORD MODIFIED Page I of 4 05/01/2007 <br />