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oPa ! -c SAN JOA UIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton ■ CA 95202 <br /> (209) 468-3420 • Fax: (209) 464-0138 • Web: www.sjgov.orq/ehd <br /> 4L�i=oR� - <br /> EMERGENCY RESPONSE RECORD 2 <br /> DATE: SHORT TERM#: C000 7 2 <br /> PREMISE iJ , � 1� CITY: <br /> ADDRESS: !/C� •` <br /> DBA: T I <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP PHONE: 92;?7-,NAME: <br /> RP ADDRESS: D�74U CITY: [I�� <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME <br /> RECEIVED: °`'���' ARRIVAL:TIMEOF f j} '" TIME OF DEPARTURE: I + I� 1 <br /> PERSONS AT SCENE [(! III 1 <br /> NAME AGENCY PHONE TOA TOD <br /> Uff 3 <br /> IDENTIFICATION OF MATERIAL(CHEY[ICAL WVOU'EW <br /> SUBSTANCE FORM 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 /> E. R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65 1 UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />