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o?°`,`' "•c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �' •i 600 E Main Street Stockton•CA 95202 <br /> r (209)468-3420•Fax:(209)464-0138 • Web:www.sigov.org/ehd <br /> RLrF�:Rta <br /> EMERGENCY RESPONSE RECORD <br /> DATE: ac� SHORT TERM#::n COOO Q <br /> ADDRESS: �.0PREMISE 1 <br /> l�(� 1nrGl/V I�,' CITY: ry` CI G�A <br /> DBA:PREMIS <br /> OW ERE Y v`LILY QTY moi/� PHONE: 0116 <br /> 1 f/_lrJ 2. <br /> 76-5 <br /> SS <br /> ADDRESS: ulac- UA JL.. CITY: Sa <br /> FACILITY PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) <br /> DBA; �lz L" ��r_' �V�^, �p <br /> - F' <br /> RP NAME: L co PHONE: <br /> RP CITY: <br /> ADDRESS: p � pi,.A �&A G <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dum ed material) <br /> fes„ S r-�CS ,r-eco C, w vi <br /> TIME /,� 7� `� TIME OF ARRIVAL: JQ rTIME <br /> OF , <br /> RECEIVED; "J i DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO I 1.POWDER GAS LIQUID <br /> GRANULE <br /> FORM .LID Q <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP UA <br /> 65: 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 I of 4 05/01/2007 <br />