Laserfiche WebLink
aZ�B� <br /> PUBLIC HEALTH SERVICES P�� ~•. <br /> SAN JOAQUIN COUNTY mho` <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer �.. P.. <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE J 121 I t SHORT TERM# <br /> PREMISE ADDRESS Ai ull l'AEc Li.,C.Sf Iv\ILII ly e} CITY 'S Ir rr-� -►.. <br /> DBA UA 9 <br /> PREMISE OWNER PHONE <br /> i <br /> OWNER'S ADDRESS ) <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RP) DBA <br /> RPNAME PHONE <br /> RP ADDRESS <br /> RPCONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> `PAu,Er BUST EZOM E,081- <br /> TIME RECEIVED 17.CA V' TIME OF ARRIVAL 17 !7th§> TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD - <br /> A MiCc V shed Fll:'- y6£^_,-431 O <br /> TL <br /> M �� � kiD 46�-z4y� <br /> IDENTIFICATION OF MATERIAL ICHEMIC.ALINVOLVED' �1 f{IN <br /> SUBSTANCE FORM '-9 SOLID '-M POWDER ❑ GAS ❑ LIQUID ❑ GRANULE i <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 /> ❑ 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 />