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o.P°'`' N•.c 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.sigov.org/ehd <br /> EMERGENCY RESPONSE RECORD / <br /> DATE: 1 J 1 O SHORT TERMLY: COOO vg <br /> PREMISE n 0 CITY: <br /> ml <br /> ADDRESS: `� f`n� <br /> DBA: Q� <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: CITY: <br /> FACILITY CONTACT: <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 /> qktl�j gbe/.o eObLz� <br /> � e+•_.�-ural ,-�w,� mak-- . <br /> TIME j /Lim TIME OF TIME OF DEPARTURE: <br /> RECEIVED: ARRIVAL: s <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 7 I!� <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED....PROP 65:7 l D UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> E.R. BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ANALYTICAL DATA I PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST CLEANUP REPORT I OTHER AGENCY REPORT <br /> REFERRALS MAP FILE CREATED <br /> ER RECORD MODIFIED Pagelof3 05/01/2007 <br />