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o ftgy1N c SAN JOAQUIN COUNTY <br /> e' Hx 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 /> A��FO <br /> EMERGENCY RESPONSE RECORD <br /> DATE: MM' SHORT TERMM Cogs 1(.•r <br /> PREMISE CITY: <br /> ADDRESS: <br /> DBA: <br /> PREMISE OWNER. PHONE: <br /> OWNER'S ADDRESS- CITY, <br /> FACILITY CONTACT PHONE: <br /> RESPONSE3LE PARTY (RP) <br /> DBA: (✓ (Vt(//� <br /> RP PHONE: <br /> NAME: <br /> RP ADDRESS: RSL CITY: U/; <br /> "CONTACT: PHONE: S <br /> NATURE OF MPLAINT( losion, ill,leak,fire,or abandoned/dumped material <br /> (44G'K c�a, e+ rdllcA� UrYi �iui d� (�q�ivL / ' � i5=?a <br /> kcsr,G �(o �vPP f-At A)b ,j,,,I;�, d y G <br /> TIME //�� TIME <br /> OF n,�.� TIME OF DEPARTURE: <br /> ARCHIVED• O ' [/D ARRIVAL: �P"//, <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> h ry -,Sly <br /> I� <br /> l/( rYl <br /> IDENTIFICATION OF MATERIAL ccxsucv.ww�vso> <br /> SUBSTANCE FORM I SOLm I I POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAB.ED: <br /> DATE COMPLBTED....PROP 65: UAR- <br /> PERSONS EXPOSED and/or INJURED <br /> 1. NAME ADDRESS PHONE <br /> `PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> E R.BINDER CO <br /> HORT-TFiRM N P KI NARRATIVE I I ANALYTICAL DAA PROP 5/ AR <br /> SURER RD MANIFEST CLEAN UP REPORT I OTHER AGENCY REPORTS <br /> REFERRALS FILE CREATED <br /> ER RECORD MODIFIED Page 1 of 05/01/2007 <br />