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SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT <br /> = 600 E Main Street Stockton• CA 95202 <br /> (209)468-3420•Fax:(209)4640138 a Web:www.sjgov.prg/ehd <br /> -a�rF:bRta <br /> EMERGENCY RESPONSE RECORD <br /> DATE: SHORT TERM//: C000 3 G..8 g <br /> PREMISE Ion <br /> G � Co, A CITY: t <br /> ADDRESS: UUCU� S{i� E_Gh" U'[ LVA, <br /> DBA: NI C \�l& e <br /> PREMISE PHONE: (%q 7)-NOWNER: UNoti dfU1A <br /> OWNER'S 11 11 <br /> ADDRESS: CITY: F <br /> oak <br /> FACILITY <br /> CONTACT: Ferree. PHONE: I 1104 6qq , <br /> 6l[ � <br /> RESPONSIBLE PARTY (RP) <br /> �1 <br /> DBA: <br /> RP NAME: +rsi< ��U PHONE: (Q[b) 431- <br /> RP ADDRESS: f b41 UV� U� oL LAM"s (A CITY: vrt�AIA&j <br /> Rp <br /> CONTACT: 11u�i�WV Cl,,.6 a PHONE: rG1r�1 <br /> NATURE OF COMPLAINT(explosion,spill, leak, fire, or abandoned/dum ed material) `l i 1 pJ <br /> Yek� i�Lrl mda� 40 6ak, U om' 4,p- fW 'r Y-A� <br /> TIMETIME OF ARRIVAL: (� TIME OF <br /> RECEIVED: ` /� DEPARTURE; ` <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 1%5 <br /> �. <br /> 7 >J L)FW `&1ce, LMA s7i-iu7 <br /> IDENTIFICATION OF MATERIAL(CHEWCAL❑vvOLVIRD)SUBSTt <br /> FORM ANCE LLIID POWDER GAS !;f LIQU GRANULE <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP [��� to UA y <br /> 65: L [[ R: <br /> PERSONS EXPOSED and/or IUR <br /> I <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page!of 4 05/01/2007 <br /> I <br />