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PUBLIC HAALTH SERVICES aPa,U,N <br /> SAN fOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION r. <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> <iFQpN <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE '- - SHORT TERM N <br /> PREMISE ADDRESS t'I CITY c5 O L �� ✓\ <br /> DBA G9& a , <br /> PREMISE OWNER <br /> OWNER'S ADDRESS PHONE <br /> FACILITY CONTACT <br /> RESPONSIBLE PARTY(RP) DBA� y. PHONE <br /> RP NAME <br /> RP ADDRESS PHONE <br /> RP CONTACT <br /> PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, tire, or abandoned/dumped materiae <br /> TIME RECEIVED TIME OF ARRIVAL Z Q ,/Q TIME OF DEPARTURE <br /> PERSONS AT SCENEE <br /> a NAME ✓ AGENCY PHONE TOA <br /> 3I 1/ d , 66s u � TOD <br /> t� v <br /> IDENTIFICATION OF MATERIAL icaeenuLINVMVMu IA-9� $ <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO ' A iF ULo,. Itiut Cc.G2 <br /> DATE COMPLETED........PROP 65 UAR DATE MAILED <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS <br /> PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP eNARRATIVE ❑ ANALYTICAL DATA pT PROP 65 / UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS &MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />