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� t <br /> P°"... SAN JOAQUIN COUNTY ' <br /> ENVIRQNMENTAL HEALTH DEPARTMENT f, p;F 7 <br /> 600 E Main Street Stockton ■ CA 95202 <br /> Ll <br /> t• <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> c i=' <br /> EMERGENCY RESPONSE RECORD QQ <br /> DATE: SHORTTERM#: COOQ �v*� <br /> PREMISEi V (X ev CITY: '' C \ <br /> ADDRESS: ` V tW <br /> DBA: %LA ` ee ft, L640 A <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: J <br /> RP PHONE: <br /> NAME: A(ex (� 9''0 s3T- 9102 <br /> RP ADDRESS: 1108, G fZ�• CITY: elA1. lA %3t <br /> RP CONTACT: le Q PHONE: W 1 W - S9oZ <br /> NATURE OF COMPLAINT(explosion, spill, leak, fine,or abandoned/dumped material) <br /> vtwA Affat- pvty le" k 4 I MiAWj oil. <br /> TIMEG�; TIME OF }f . TIME OF DEPARTURE: I <br /> RECEIVED: , ARRIVAL: Ill <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> � E CUR m-7 -S401- <br /> ��- C q6S- 53 0� ! It-r(W <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <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 NARRATIVE AL I AR <br /> RECORD MANIFEST AGENCY REPOR <br /> REFERRALS A <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />