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oP" •"_ 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 /> AL/FORS <br /> EMERGENCY RESPONSE RECORD <br /> DATE: ` ,Lj + p SHORT TERM#: COOO <br /> PREMISE CITY: <br /> ADDRESS: <br /> DBA: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: �Q�( ( _� n PHONE: <br /> RESPONSIBLE PARTY (RP) <br /> DBA: <br /> RP PHONE: <br /> NAME: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> b� r-&jj�4- w�,r�i1�a 20, r q t; <br /> u,p zp a,*a !yta0 akt�,l <br /> TIME 1 a TIME OF ' s TIME OF DEPARTURE: <br /> ARRIVAL: <br /> RECEIVED: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 5 •W <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65: 1 I D UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL <br /> TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> R. BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEAN UP REPORT OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Pagelof3 05/01/2007 <br />