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PUB11C <br />HEALTH SPRVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton, CA 9 <br />209/468-3420 <br />EMERGENCY RESPONSE RECORD <br />DATE ///z c <br />PREMISE ADDRESS _ <br />DBA <br />PREMISE OWNER _ <br />OWNER'S ADDRESS <br />FACILITY CONTACT <br />sv.rn." <br />'57 � ''r i Up s % - e5 , 3 C, <br />RESPONSIBLE PARTY (RP) DBA STiri Tim SGc' - <br />RP NAME <br />RP ADDRESS 1 6 S t✓/I v=fr vY 'Anr46 <br />RP CONTACT <br />COO U <br />>HOR TERM # Com <br />=111 <br />CITY /.,f f 4;n <br />PHONE <br />PHONE <br />PHONE <br />NATURE OF COMPLAINT (explosion(SZ. )cak. fire. or abandoned/dumped material) <br />^ l r D�� TIME OF ARRIVAL `` , "f 1 TIME OF DEPARTURE <br />TIME RECEIVED (Mb) <br />(TOA) <br />PERSONS AT SCENE ,, Tr) a TOO <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) GAS LIQUID [ ] GRANULE <br />SUBSTANCE FORM:[ ] SOLID [ OWDER [ ] <br />REFERRALS TO: -� tc4 DATE MAILED: ,Q 7 <br />DATE COMPLETED: PROP 65 UAR IY <br />PERSONS EXPOSED and/or INTJURED <br />NAME ADDRESS <br />•'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED'' [ ] YES <br />E. R. BINMER COPIES: <br />SHORT-TERM ON TOP _f,/j NARRATIVE [ J ANALYTICAL DATA <br />[T EXPOSURE RECORD [ ]MAPIFEST FILE CREATEDCLEAN UP ORT <br />[ ] REFERRALS [,jM <br />EH 22 014 4/96 <br />A Division of San Joaquin County Health Care Services <br />PHONE NO. <br />[] NO <br />[ ] PROP 65/UAR <br />[ J OTHER AGENCY REPORTS <br />