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PUBLIC HEALTH SERVICES <br /> �o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer �.. <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> DATE ,1 + y � 0d <br /> EMERGENCYln3) RESPONSESHORT TERMORD <br /> PREMISE ADDRESS ,1 0 CITY i <br /> DBA <br /> r^ <br /> PREMISE OWNER /Yr �- C�0h7m//Nr <br /> OWNER'S ADDRESS i!_ .S^ <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RP) DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion. spil , leak, fire, or abandonyd/dumped material) <br /> TIME RECEIVED TIME OF ARRIVAL , / TIME OF DEPARTURE <br /> PERSONS AT SCENE d,'3 tt S S'c/ Cti <br /> NAME 41 AGENCY PHONE A TOA TOD <br /> IDENTIFICATION OF MATERIAL�CHEWCILiNIOUWi <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTA.VCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E.R. BINDER COPIES: �/ <br /> SHORT-TERM ON TOP Jd NARRATIVE ❑ ANALYTICAL DATA C3 PROP 65 / UAR <br /> ❑ EXPOSURE RECORD X❑ NIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> A Division of San Joaquin Count: Health Care Services <br />