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Pq�(" 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.org/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: pas 0 SHORT TERM#: C000 <br /> PREMISE CITY: rlj� <br /> ADDRESS: Ic'u0cf <br /> (�(�(�, U/ v <br /> DBA: <br /> PREMISE PHONE: <br /> OWNER: s 'r- <br /> OWNER'S ADDRESS: ,� cM Q CITY: h� <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY (RP) � �{ /� �J <br /> DBA: ��✓ <br /> RP PHONE <br /> NAME: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak,fire,or abandoned/dumped material <br /> VI /fU k2ta&,5 ' 07? 7'-D ,Jl I-e-_ aid a.7 rfr�z� <br /> 7'z-e 417Lt ej�a l�d ayo�fzz <br /> n <br /> TIME RECEIVED: / [/ TIME OF ARRIVAL: /-�DGI,/yT TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM I I SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65: UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> R.BINDER COPIES: <br /> SHORT-TERM ON TOP ARRATIVE ANALYTICAL DATA PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD ELECTRONIC VERSION Page 1 of 4 01/16/09 <br />