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4 <br /> " I I COPY <br /> IN SAN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Strut Stockton a CA 95242 <br /> (209)468-3420•Far:(209)464-0138■Web:www.sixov.oreehd <br /> Lr <br /> EMERGENCY RESPONSE RKC—QR <br /> DATE: S�,l�� 2Z 2pt7 9 SHORT TERMk: C0, a 8 <br /> ADDRESS: <br /> neA: C CL JP v /\ <br /> PRE c pC `� (,.V OL T t 1 PHONE: <br /> AS <br /> k3 �-60057 <br /> OWNER: `� �� ) �j <br /> OWNER'S �'-�-� VV • ��W 1L � CITY. �Y�0.0 { <br /> ADIlRESS: <br /> FACILITY r.r()A,- PHONE: ••Cad O <br /> CONTACT: a <br /> RESPONSIBLE PARTY (RP) <br /> k DSA: <br /> TLP NAME. PHONE: <br /> i RP. CrrY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE URFi OF COMPLAINTcz anion,s ill,leak,fire,or a bu donedtdum material); <br /> Concpla[�q, S-f - a. pf le c-P Mj-�-J rgt"..*x4o r <br /> ptmPkr f0, /�a ct rrb.rtP.+t 5.2 o _^�'� �`•2 �a LCEA a�' 11.SC <br /> pfGiarct O^A Q Sot t ( 21Y1►�SQ, <br /> TIMEf a�ri TIME OF ARR1vAL: I Z DEPARTURE:- of • >Op <br /> Al <br /> RECEIVED: •r�-+ <br /> PERSONS AT SCENE <br /> NAME ADEN Y PFlO TOA DOD <br /> 966Q-Y-4- Logg G des 5 z9Y5 10% ISA <br /> -a3 12 PM <br /> S 65 953 4 200 <br /> Va <br /> S ti l�-9$ZSti <br /> iq<-,3 ILI <br /> ENTIFICATION OF MA RIAL t.u+. ' <br /> LSU ANCE . POWDER GAS LIQUtg GRANUIX FOIj <br /> REFERRALS DATE <br /> TO.- MAILED: <br /> DATE IsQPT.ETED:. PROP 1 _0 � f UA <br /> 65: R. <br /> PERSONS EXPOSED and/or INJURED <br /> ADDRESS H <br /> 'PE. TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> ER RECORD MODIFIED Page I of 4 �5181/20p7 <br /> - 1 <br />