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p Qu?N 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: SHORT TERM#: 0004 <br /> ID <br /> V3 09 <br /> PREMISE y j CITY: <br /> ADDRESS: vV �-✓ �^� <br /> DBA: <br /> PREMISE OWNER: �7 fK,,,�( PHONE' Lf�jb �Y0� <br /> OWNER'S ADDRESS: -,770C)' (..� Us rJ CITY: <br /> FACILITY CONTACT: f PHONE: p-] <br /> ttit <br /> RESPONSIBLE PARTY (RP) <br /> DBA:RP •� "^ <br /> r_ PHONE: / 1 t 0-7 <br /> NAME: ✓`^""' c� <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, lire, or abandoned/dumped material) <br /> 1 <br /> TIME ~_ TIME OF Z l5 TIME OF DEPARTURE: <br /> RECEIVED: ARRIVAL: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> -- �•+v. Com, Slo-Z3f-'-}70 3'3� <br /> V%71c% Sc � ' <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65: 3 QR UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> <br /> <br /> E.R. BINDER COPIES: <br /> HORT-TERM ON TOP NARRATIVE �FICAL DATA PROP 65 1 UAR <br /> RECORDREFERRALSEATED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />