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,y s <br /> PUBLIC HEALTH SERVICES �oP .co <br /> SAN JOAQUIN COUNTY �•' �� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue,Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE t'CJrJ (�•r r� t SHORT TERM# d 1372-D <br /> PREMISE ADDRESS e� r WGL CITY <br /> DBA— <br /> PREMISE OWNER POW `Ql.v� 1 ��O P/Y�� S SPHONE <br /> OWNER'S ADDRESS 18253 S . RI r± <br /> FACILITY CONTACT UaVA SII C PHONE <br /> RESPONSIBLE PARTY <br /> �(RP) DBA F <br /> RP NAME J ,XY1 G� r�iL PHONE <br /> RP ADDRESS S PFI {Y t0 L7��' W Cwt <br /> RP CONTACT "nQ/Y� I 1 V _ PHONE ZG�(— <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED JZ•I OPM TIME OF ARRIVAL Q&A TIME OF DEPARTURE .Z5`PM <br /> PERSONS AT SCENE 1� � d ` �M (0 3 M <br /> NAME AGENCY PHONE TOA TOD <br /> Al I o (AY10 Wod 4S-. <br /> s D <br /> DM <br /> IDENTIFICATION OF MATERIAL 11.1.1CALNVOLVrD) Kian4Q <br /> SUBSTANCE FORM ❑ SOLID ■ POWDER ❑ GAS IRV 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 /> A SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 65 /UAR <br /> 13 EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT E1 OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> EH22014rev.doc A Division of San Joaquin Counry Healrh Care Services 6/14/1g9� <br />