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POUiry SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton•CA 95202 <br /> P. (209)468-3420•Fax.(209)464-0138 • Web:www.sjPov.orwchd <br /> 4C/PORN <br /> EMERGENCY RESPONSE RECORD <br /> DATE: �_ G, _ �� SHORT TERM#: <br /> C0003(`a'Llci <br /> PREMISE CITY: g'�o <br /> ADDRESS: /0-2,( <br /> DBA: �-- rr+ <br /> PREMISE PHONE: <br /> OWNER: 4— *' <br /> OWNER'S <br /> ADDRESS: I SLI �Q,,.�¢.� 1FACITY <br /> crrY: � <br /> CONTACT: o arPHONE: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: rX T <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: 1— qX— <br /> NATURE OF COMPLAINT(explosion, spill, leak, tire,or abandoned/dumped material) <br /> L Cwt'C Cao 5A(ty. c ?ion/ H02 <br /> TIME TIME OF ARRIVAL: TIME OF <br /> RECEIVED: • ?j C7 DEPARTURE: c-- <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMIM INVOLVED( <br /> FORM STANCE LID POWDER GAS }p LIQUID GRANULE <br /> REFERRALS DATE <br /> TO: N O <br /> DATE COMPLETED....PROP UA <br /> 65: ZZ-7-10 R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> no•.` <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page l of 4 05/01/2007 <br />