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PUBLIC HEALTH SERVICES <br /> Pau�N <br /> �.;�-,ate':•o <br /> SAN JOAQUIN COUNTY <br /> f ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> f 209/468-3420 <br /> I EMERGENCY RESPONSE RECORD <br /> DATE 4SHORT TERM # <br /> PREMISE ADDRESS CITY2I7-elm <br /> DBA T' <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> f FACILITY.CONTACT PHONE <br /> f RESPONSIBLE XARTY (RP) DBA t 'T— <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHO E' <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire..or a andoned/dumped material)_ — [aA69� _ :Qk- <br /> �l +A0 <br /> tr j Ck 11kJ OC I i C S} -`b <br /> TIME RECEIVED L',bO. LIC", TIME OF ARRIVAL [o'.F! AWS TIME OF DEPARTURE !16 MY) <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> N E AGENCY PHONE NO. TOA TOD <br /> 17 <br /> �poa <br /> 1 <br /> IDENTIFICATION OF MATERIAL (CMAICALINVOLVED) <br /> SUBSTANCE FORM: [] SOLID [ ] POWDER [ ] GAS LIQUID [ ] GRANULE <br /> i - <br /> REFERRALS TO: {{ DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> r' <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [] YES [I NO <br /> E. R. BINDER COPIES: <br /> [r]HORT-TERM ON TOP (,r A5ATrVE (] ANALYTICAL DATA [4-TROP 65/UAR <br /> [J EXPOSURE RECORD [ ] MANIFEST (] CLEAN UP REPORT (] OTHER AGENCY REPORTS <br /> (JREFERRALS [�'l�tAP [] FILE CREATED <br /> EH 22 014 4/96 <br /> A Division of San Joaquin County Health Care Services <br />