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PUBLIC HtALTH SERVICtS OPOUIry <br /> SAN JOAQUIN COUNTY r. - <br /> P: � <br /> ENVIRONMENTAL HEALTH DIVISION ".ILL ` <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 "c4i6a+ <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM N <br /> PREMISE ADDRESS CITY �� G <br /> DBA R On <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DBA J3 'rl <br /> RP NAME 77�� PHONE a O —� <br /> RP ADDRESS c;��77V D <br /> -25 <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> kjj <br /> 41 4z ldf 'e <br /> �v <br /> TIME RECEIVED . D TIME OF ARRIVAL J Q.' / b TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> QM 1011 L(_15 11 :05 <br /> /Iliit.V <br /> omthl TI ::tnU <br /> a �© <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO ADA/TE MAILED <br /> A <br /> DATE COMPLETED........PROP 65 Jr— — UAR A <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 ❑ 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 />