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o?°"I."- SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton■CA 95202 <br /> (209)468-3420 •Fax:(209)464-0138 • Web:www.sigov.orOehd <br /> 4M ORS <br /> EMERGENCY RESPONSE RECORD <br /> DATE: Z 5 SHORT TERM#: CO00 <br /> PREMISE CITY: r <br /> ADDRESS <br /> DBA: /Y LD Vl <br /> PREMISE PHONE: <br /> OWNER: <br /> OWNER'S CITY: <br /> ADDRESS:FACILITY <br /> /� - <br /> CONTACT: e Uel- (I t7 S-5L.0( PHONE: �`7 1� � � ]c7 3132 <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME TIME OF ARRIVAL: TIMEOF <br /> RECEIVED: DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS �[ LIQUID -T-- GRANULE <br /> FORM LID !� Q <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP S� �f 1 { UA <br /> 65: 7 R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page 1 of 4 OSIOI/2007 <br />