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t , <br /> o?°: "• 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: _ (3 [ SHORT TERM#: CO00PREMISE <br /> ADDRESS: <br /> C V CITY: i <br /> DBA: g,c IV tC I C t <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY (RP) E 7 C ('40A <br /> 0 n <br /> DBA: (� <br /> RP PHONE: <br /> NAME: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: —0 d PHONE: 3 `(<L <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME TIME OF ( _ TIME OF DEPARTURE: L j� <br /> RECEIVED: ARRIVAL: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: I 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? _TTYES FT-NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA I PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEANUP REPORT I OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Page Iof3 05/01/2007 <br />