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PUBLIC HEALTH SERVICES a�A4UIM O <br /> SAN JOAQUIN COUNTY = <br /> ENVIRONMENTAL HEALTH DIVISION ` <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer ,. " <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 etFoe <br /> (209) 468-3420 <br /> 11 <br /> DISTRICT # DATE <br /> FSffiRGENCY RESPONSE RECORD SHORT TERM #(/I VOSR <br /> I / <br /> PREMISE ADDRESS .3//30 S � ��d (l 0 d heal ,�c� crrr 1�'gCy <br /> DSA 1.%/ -- <br /> PREMISE OWNER �C /JOG I 'U{'l � PHONE <br /> OWNERVS ADDRESS <br /> FACILITY CONTACT ('Tdu �d PHONE <br /> NATURE OF COMPIAIN'T 1 n, spill, lesiti or abandoned/dumped material) - <br /> - / / / //Yd / 411 P, f G ly <br /> T o I zr 0' /n i '9 � iy r/�/liY"L raj,TN/• <br /> CC i <br /> TIME RECEIVED 0. ��+ TIME OF ARRIVAL IDOD TIME OF DEPARTURE a 30 <br /> (TOA) (T00) <br /> PERSONS AT SCENE <br /> AGENCY P ONE NO. TOA TOD <br /> D.'ol <br /> IDENTIFICATION OF MATERIAL. (CHEMICAL IWVMVED) <br /> SUBSTANCE FORM: [ I SOLID <br /> [ I POWDER [ I GAS hQ LIQUID [ ] GRANULE <br /> REFERRALS TO: SSG / /c Lt/(YC' DATE MAILED: <br /> DATE COMPLETED: PROP 65 �� �j��3 97 DAR /V1/g <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> Z�111 <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ I NO <br /> E_R_BINDER COPIES: <br /> SHORT-TERM ATTACHED ON TOP XNARRATIVE [ I ANALYTICAL DATA PROP 65/UAR <br /> u[ ] 'E POSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ I OTHER AGENCY REPORTS <br /> / 44 -FERRALS [ I MAP [ I FILE CREATED <br /> > f�,pion of San.)oaquin Comms Health Ears Ser%ice, <br />