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SAN .TOA <br /> QUIN COUNTY <br /> ��� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton • CA 95202 <br /> (209)468-3420•Fax.(209)464-0138 • Web.www.sieov ore/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: — � Ocl <br /> SHORT TERM#: <br /> C0 <br /> 0b0 �� o <br /> YPREMISE CT : AADDRESS: <br /> DBA: <br /> PREMISE PHONE: 55rY c <br /> OWNER: .._J CC C�no ¢f.5v____ ZSSSS <br /> ADDRESS: 2� ) YG or-'I-4- COY12 <br /> G'/ �✓o <br /> FACILITY /' PHONE: <br /> CONTACT: -}'«- ��n r(5'�b tia+�fn,` ZO 515 S <br /> RESPONSIBLE PARTY (RP) <br /> DHA: SW 1 s bard G..-.. 4in u b c <br /> RP NAME: /' Yi c PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire,or abandoned/dumped material) <br /> wov.fCN 'OA)c �.— �'rC�„-..'�-f•,-. ey..cP TIME TIME OF ARRIVAL: h I S TIME <br /> DEPARTURE: OF <br /> RECENED: , <br /> � p t.,.� <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> G <br /> 121K <br /> -11 -^ SS <br /> IDENTIFICATION OF MATERIAL(CasMIcu.INWLV D) <br /> SUBSTANCE SO POWDER GAS LI UID GRANULE <br /> FORM LID Q <br /> REFERRALS /� -rte n DATE 6 � <br /> TO: OSF)A — 'Jq�l K q Vey MAILED: <br /> DATE COMPLETED....PROP ��)2 v 9 UA <br /> 65: V R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> Uw <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES )! NO <br /> ER RECORD MODIFIED Page 1 of 4 05/01/2007 <br />