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PUBLIC HEALTH SERVICES <br /> SAM JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION " <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-4388 <br /> 209/468-3420 <br /> 04ERGE`ICY RESPONSE RECORD <br /> GATE `� SHORT TERM 4GOce�5:(j�i <br /> 'REMISE ADDRESS �GAv /!/ CIT'Y `-i OGS bs I <br /> JRA �A c or G4L iFae Gris�'TE,�u� `� <br /> 'SENUSE OWNER PHONE <br /> ER'S ADDRESS <br /> -ACLLITY CONTACT PHONE <br /> ZESPONSIBLE PARTY (RP) DBA el-4. <br /> KP NAME i/ .K. PHONE v A:�. <br /> kP ADDRESS <br /> RP CONTACT_ a PHONE v- L-- <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped aurerial) e—"v55 <br /> TIME RECEIVED—S' '/,:14"7 TIME OF ARRIVAL TINE OF DEPARTURE VC7 <br /> C70A) (TOD) <br /> PARSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> iCf/l fid .5� 0 D %7` <br /> 5-_37-7 <br /> ^JENTIFICATION OF MATERIAL �ct(e.icu.mvo�vm� <br /> SUBSTANCE FORM: ( ] SOLID [ ] POWDER [ ] GAS YLIQUM [ ] GR U4T= <br /> REFERRALS TO:A14A DATE MAILED: ,J//.A- <br /> DATE COMPLETED: PROP 65 9/y �7 UAR _SCT44' <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? ( j 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 ( ] OTTER AGENCY REPORTS <br /> [ ] REFERRALS [ 1 MAP [ 1 FILE CREATED <br /> EH 22 014 4/96 <br /> A Di%ision of San(oaa;:in Counry Health Care Sen ices <br />