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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E 'Main Street Stockton ■ CA 95202 <br /> ` (209) 968-3420 Fax: (209) 464-0138 Web <br /> C' rc : www.sjgov.org/ehd <br /> 0 <br /> EMERGENCY RESPONSE RECORD <br /> DATE; sb W SHORT TERM#: COOO <br /> PREMISE ! ,�y „` <br /> ADDRESS: '�j[� �*! CITY; <br /> DBA: S U <br /> PREMISE OWNER: V4 PHONE: <br /> OWNER'S ADDRESS: CITY. <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY (RP) C> <br /> DBA: <br /> RP <br /> NAME: <br /> PHONE: DO le <br /> RP ADDRESS: VIP) CITY: ' <br /> RP CONTACT: PHONE: 4NAlb <br /> NATURE OF COMPLAINT(explosion: spill,leak, fue, or abandoned/dumped material) <br /> "+ P,euir w wi ri OF Saw ami y <br /> ccc C;vMver�e. <br /> TIME rr TIME OF I TIME OF DEPARTURE: <br /> RECEIVED: 4 D�5 ARRIVAL: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> a� 15T1�-A ku D <br /> i ' r <br /> 61 <br /> IDENTIFICATION OF MATERL4L(CHEMICAI,INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER I 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 /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP I INARRATIVE ANALYTI AL DATA PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP RE RT THER AGEN Y REPORTS <br /> REFERRALS I FILE FATED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />