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PUBLIC HEALTH SERVICES ,9A c,0, <br /> SAN JOAQUIN COUNTY ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health OfficerP.. <br /> 304 East Weber Avenue, Third Floor• Stockton, CA 95202 <br /> 209/468-3420 <br /> /, EMERGENCY RESPONSE RECORD <br /> DATE Z !/f,7 (( SHORT TERM# OO 6 Zd U <br /> PREMISE ADDRESS D� J�, 07 CITY <br /> DBA <br /> PREMISE OWNER �G�Y� PHONE �? — S '✓U <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT J /� J PHONE h1L ' 3�5 <br /> RESPONSIBLE PARTY (RP)DBA / l/� a 1/JI1(!/' G�- tH <br /> RP NAME J'/ � PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> �. <br /> NATURE OF COM AINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> O <br /> TIME RECEIVED d TIME OF ARRIVAL Ste'S'y TIME OF DEPARTURE 'dD <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) L� <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER GAS ❑ LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 d U ' UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> C, - ? 6 <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> "SHORT-TERM ON TOP )XNARRATIVE ❑ ANALYTICAL DATA PROP 65/ UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> EH22014rev.doe A Division of San Joaquin County Health Care Services 6/14/1999 <br />