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0 SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPARTMtNT <br /> 600 E Main Street Stockton • CA 95202 <br /> c. ' ..•� (209) 468-3420 • Fax;(209) 464-0138 • Web;www.sjgov.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: to ( SHORTTERM#: 0000 <br /> PREMISE ADDRESS: ��( �1 ( -fty , CITY: <br /> DBA: II I L <br /> PREMISE OWNER: PHONE: <br /> OWN ER'S ADDRESS: CITY: n'I <br /> FACILITY CONTACT: Iwl PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: I` <br /> RP NAME: PHONE: <br /> RP ADDRESS: CIN: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> TIME RECEIVED: �•1 TIME OF ARRIVAL: 2 dO �lY'� TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> V,WWA s �fy Lt N <br /> Irt a 3d su;, IHDo fCG*c� <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE CIDM PLETED....PROP 65: I Z UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65/U <br /> EXPOSURE RECORD MANIFEST CLEANUP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page 1 of 4 10/21/09 <br />