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•`fes <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY 2. <br /> ENVIRONMENTAL HEALTH DIVISION , , <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor - Stockton, CA 95202 4`�FORa <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM# <br /> PREMISE ADDRESS M 6 L rJ � AeV A-&1S CITY ��Q <br /> DBA rA efOtt )e-p in <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS _r051rZA Aon CA <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RI� DBA 51Y10_�� <br /> RP NAME �r�Y�t "P4IzeILIPHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or aban oned/dumped material) <br /> 11 w <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Jar �i L g .�.� SLt► <br /> Dori <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) —k-7)w <br /> SUBSTANCE FORM 13 SOLID ❑ POWDER 1:1 GAS LIQUID ❑ GRANULE <br /> REFERRALS TO 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 /> ER SHORT-TERM ON TOP Cid NARRATIVE ❑ ANALYTICAL DATA PROP 65 / UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS -WMAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />