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r <br /> PUBLIC HEALTH SERVICES <br /> PQ,U.�N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 4��FO.Ra <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 2091468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE M2 C &0 hh SHORT TERM!# <br /> PREMISE ADDRESS S Z S (�. J- • P"ate. _ CITY <br /> c <br /> DBA \ AD A <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS _ <br /> FACILITY CONTACT PHONE Z O <br /> a <br /> RESPONSIBLE PARTY(RP)DBA _ <br /> RP NAME ` &0. <br /> �-� PHONE <br /> 1 <br /> SSE' <br /> RP ADDRESS SRZT LO- ,ACAC1�-- - <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandonedldumped material) <br /> r "y"A <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> V C,0_ <br /> -NPA LUb <br /> zS S - `-ICS 359 <br /> IDENTIFICATION OF MATERIAL(CHEMiCALNVOLVEa) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER EVGAS ❑.LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> il <br /> NAME ADDRESS PHONE <br /> r <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP 13 NARRATIVE ❑ ANALYTICAL DATA 13 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 />