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low 71LE COPY <br /> TH <br /> PUBLIC HEAL SERVICES G <br /> SAN JOAQUIN COUNTY , <br /> U): <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer C..._ <br /> 4L�FORt� <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> J EMERGENCY RESPONSE RECORD// <br /> DATE �[ " SHO T TER # C_ Q <br /> PREMISE ADDRESS �S Q 1 S �c-[ �^� M CITY <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP) DBA SLi C—U <br /> PHONE <br /> RP NAME <br /> 3 — <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, tire, or abandoned/dumped material) <br /> J <br /> ( S6 <br /> TIME RECEIVED TIME OF ARRIVAL Q t­� TIME OF DEPARTURE -�fl <br /> PERSONS AT SCENE <br /> NAME AGENCY PHOONEU TOA TOD <br /> a U s 'k L) - <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID <br /> pp ❑ POnW^DER, _ C-1GASIQUID ❑ GRANULE <br /> REFERRALS TO fQ _ C— lh�C,,XA! \ DATE MAILED <br /> DATE COMPLETED ........PROP 65 UAR <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 />