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PUBLIC HEALTH SERVICES <br /> TQUIn, <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 95201-0388cq`/F6,f9t <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> -)ATE -:;f ��. C✓ SHORT TERM 4 <br /> 'REMISE ADDRESS �� 1 CITY �1 <br /> BA <br /> -REMISE OWNER PHONE <br /> WNER'S ADDRESS <br /> kCII.TTY CONTACT PHONE f9c?,Z— /(LS'L <br /> .ESPONSIBLE PARTY (RP) DBACl �� <br /> tP NAME PHONE C_='C c <br /> ::P ADDRESS C', <br /> �P CONTACT PHONE n <br /> ;NATUR OF COMPLAINT ezplosio spill. leak or abandoned/dumped material) <br /> !?vM RECEIVED ?-Q 4C1 V TR,4E OF ARRIVAL L— TRIE OF DEPARTURE <br /> CrpA) (TOD) <br /> .ZSONS AT SCENE <br /> NAME AGENCY PHONE N0. TOA TOD <br /> Lam - l_\tea� S�ccktU.�,u L +,)4 - <br /> 11 31 c,ivt� 4'' S� <br /> DENTIFICATION OF MATERIAL (CHeAICALINVOLVFD) <br /> LBSTANCE FORM: ',[SOLID [ ] POWDER [] GAS XLIQUID [] GRANULE <br /> EFERRALS TO: DATE MAILED: <br /> ',ATE COMPLETED: PROP 65 _�� �7 UAR <br /> -ERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE N0. <br /> PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [] YES ( I NO <br /> R. BINDER COPIES: <br /> SHORT-TERM ON TOP VKNARRATIVE [ ] ANALYTICAL DATA PROP 65/UAR <br /> 1 EXPOSURE RECORD [ ] MANIFEST [ ] CLEAN UP REPORT [ ] OTHER AGENCY REPORTS <br /> I REFERRALS ,[ MAP FILE CREATED <br /> 11 22 014 4/96 <br /> A Division of San loaaum Coumv Health Care 5e ices <br />