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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DVnSION n' <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 304 E.Weber Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 �9�iasa ' <br /> 209/468-3420 <br /> E1dMGENCI RESPONSE RECORD SHORT TERM :f <br /> DISTRICT � DATE I z��3 1 n <br /> ?REMISE ADDRESS 4 <br /> DBA <br /> PRENIISE OWNER +`(�-fn.rnJ H -?HONE <br /> OWNERS ADDRESS U wl�Mu*JN <br /> FACII.11'! CONTACT PHONE <br /> NATURE qF COMPLAINT (explosion, sptll, leak ore. or a ned/d=ped material) <br /> / p 4Ul�Ax wLtaai r `h GJak �• <br /> t <br /> TIME RECEIVED /#'r1 TIME OF ARRIVAL Ci•% ,'T?• TIME OF DEPARTURE U(TCLo3 4d <br /> (TCA) <br /> PERSONS AT SCENE <br /> N,�� AGENCY PHONE NO. TOA TOD!J/0 <br /> A[crtaYG / 69� �) I :/3 R <br /> ZrrareR/• �J.rvie-/-( rh le-/� J Garm �r1a 7 Z7 oz 1 r-r aD R., <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: C 1 SOLID [ I ?OWDE2 C I S C I LIQUID C I GRAi`IUI.E <br /> REFERRALS TO: DATE VAI E1: <br /> DATE COWL--=: PROP 65 UAR <br /> PERSONS E:l�OSED and/or INJURED PHONE NO. <br /> NAME ADDRESS <br /> 'PERSONAL TOXIC SUBSTANCE- EXPOSURE RECORD" COWL=' ' [ I YES C I NO <br /> I- R. 32MER COPIES: <br /> i/6,10 RT-TFtm AT-.AC:-= ON TOP M NARRATIVE [ 1 ANA-`TICAL DATA C I PROP 65/UAR <br /> I --%POSURE RECORD [ ] y1ANIFES [ ] C=1NUP FIItM REPORT [ ? OTHER AGr'YCY REPORTS <br /> C I REFERRALS ( IAP [ l FILE CREATED <br /> A Division of San Joaquin County Health Cate 5micc <br />