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PUBLIC HEALTH SERVICES )�POu'N <br /> SAN JOAQUIN COUNTY r. <br /> ENVIRONMENTAL HEALTH DIVISION U) <br /> Karen Furst, M.D., M.P.H., Health Officer ` <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE `� SHORT TERM # <br /> PREMISE ADDRESS 03 O'er+ ��' A--45S-Cr( CITY <br /> DBA G./ <br /> PREMISE OWNER PHONE l ZZ --3 ';1.QZ <br /> OWNER'S ADDRESS /ry <br /> FACILITY CONTACT =-'r.41 Z-'34 C.4 rLsl. .� /St PHONE <br /> RESPONSIBLE PARTY (RP) DBA _5,/A A1S'a✓f <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, sj!5>ak, lire, or abandoned/dumped material) jai,C_525P_' <br /> .i <br /> t <br /> TIME RECEIVED TIME OF ARRIVAL Z4ar.4 TIME OF DEPARTURE <br /> f (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> i <br /> i <br /> 1 <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [] SOLID [] POWDER (] GAS IQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: IV114' <br /> DATE COMPLETED: PROP 65 �/6/ ' UAR N l� <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> r <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ( ] YES [] NO <br /> E. R. BINDER COPIES: <br /> [] SHORT-TERM ON TOP [] NARRATIVE [] ANALYTICAL DATA [] PROP 65/UAR <br /> [ ] EXPOSURE RECORD [] MANIFEST [ I CLEAN UP REPORT [] OTHER AGENCY REPORTS <br /> [] REFERRALS [ ] MAP [ ] FILE CREATED <br /> EH 22 014 4/96 <br /> A Division of San Joaquin County Health Care Services <br />