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PUBLIC HEALTH SERVICES ��A4UIy <br /> SAN JOAQUIN COUNTY ? <br /> ENVIROtil1ENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto. M.D., M.P.H., Acting Health Officer <br /> CiFpp <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 368-3420 <br /> ��..� EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE t t SHORT TERM Pr OOP 3 <br /> PREMISE ADDRESS L (x7- � <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> NATURE OF COMPLABJT (explosion, spill,1mr,fire, or abandoned/dumped material) <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> IDENTIFICATION OF MATERIAL (CHEMICAL IMVED) <br /> SUBSTANCE FORM: [ l SOLID (] POWDER [ ] GAS ( ] LIQUID ( l GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> ADDRESS PHONE NO. <br /> NAME <br /> "PERSONAL TOXIC SUBSTANCEE�'.._��..'....r�nn+ r�>,T��+±Trn r 1 YES ( ] NO <br /> E.R.BINDER COPIES: Karl N. Barber <br /> Gaolaglst �� <br /> [ I SHORT-TERM ATTACHED ON I :OP 65/UAR <br /> [ l EXPOSURE RECORD TIER AGENCY REPORTS <br /> Environmental Consultants 6761 Sierra Court <br /> [ ] REFERRALS Suite D <br /> Dublin, CA 945602611 <br /> 510 829-0661 <br /> FAX 510 829-5493 <br /> 'fid' <br />