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PUBLIC HEALTH SERVICES <br /> POUIN <br /> SAN JOAQUIN COUNTY <br /> r. <br /> ENVIRONMENTAL HEALTH DIVISIONT• -°' <br /> N: t < <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer b <br /> 304 E.Weber Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 oq�.Fo.R <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE r�SHORT TERM# <br /> PREMISE ADDRESS ''CO 21123 S. Tc,IC 26 CITY <br /> 1 <br /> DBA <br /> PREMISE OWNER — PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT — PHONE <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, abandon dumped material) �.. <br /> rGrorr txn � G*JC3s',do,c� C>1 � do � fbr <br /> U <br /> TIME RECEIVED TIME OF ARRIVAL 2(O'40 hr' TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> Ar-r�,rrFlc� 1 OES 4 o (c� <br /> gca�• F-l"d��� r;.c � � - Uoo <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) �UIJ��' iC1e 2S I'JP <br /> SUBSTANCE FORM: [ 7 SOLID POWDER [ I GAS [ 7 LIQUID ( ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 \3aY\ UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES A� NO <br /> E. IL BINDER COPIES: 777,,,���( <br /> [ 7 SHORT-TERM ATTACHED ON TOP [ ] NARRATIVE [ 7 ANALYTTCAL DATA A111,PROP 65/UAR <br /> ( 7 EXPOSURE RECORD [��]/!MANIFEST [ ] CLEANUP FIRM REPORT '[ ]\OTHER AGENCY REPORTS <br /> Up <br /> [ 7 REFERRALS MAP [ 7 FILE CREATED <br /> / A Division of San Joaquin County Health Care Services <br />