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PUBLIC HEALTH SERVICES <br /> SAN 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 95201-0388 /FOR <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT # DATE r �Q SHORT TERM# <br /> PRE ^E ADDRESS �- C CITY rook <br /> DBA i7 PHONE �— <br /> PREMISE OWNER <br /> OWNER'S ADDRESS PHONE Z1 I t, 7,` <br /> FACILITY CONTACT <br /> RESPONSIBLE PARTY (RP) DBA I,� lZ R _PHONE <br /> RP NAME <br /> RP ADDRESS I�C�Y7 PHONE <br /> RP CONTACT <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED -�'A."^ TIME OF ARRIVAL C� f'r'� TIME OF DEPARTURE <br /> (TOA) (POD) <br /> PERSONS AT SCENE <br /> AME AGENCY PHONE NO. TOA TOD <br /> I C(, le t ori) q b 6 <br /> �z7 Z <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) d2cGRANULE <br /> SUBSTANCE FORM: [)'SOLID [] WDER [] GAS LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [] YES [] NO <br /> E. R. BINDER COPIES: ,�( <br /> 1l PRO <br /> (�`6HORT-TERM ATTACHED ON TOP [` -MANIFESTS [ ] CLEANUP AFIRMDATA <br /> REPORT t( ] OTHERS AGENCY REPORTS <br /> [ ] <br /> EXPOSURE RECORD [[4 MAP (] FILE CREATED <br /> [ ] REFERRALS <br /> EH 22 014 4/96 <br /> A Division of San Joaquin County Health Care Services <br />