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t <br /> PUBLIC HEALTH <br /> SERVICES au�N <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., 3rd Floor • P. Q. Box 388 • Stockton, CA 95201-0388 .. <br /> 209/468-3420 <br /> DISTRICT # 3�73 DAT EMERGENCY RESPONSE RECORD <br /> SHORT TERM# 9b <br /> PREMISE ADDRESS S c <br /> 2-1 <br /> CITY <br /> DBA r t6r l <br /> r <br /> PREMISE OWNER S <br /> PHONE y�LS -79 <br /> �_. <br /> OWNER'S ADDRESS �{ t7 C' cf - <br /> FACILITY CONTACT <br /> NATURE OF COMPLAINT (explosio PHONE 2-") <br /> $Pi11, �k Ere, ora doned/dupped material) <br /> of <br /> TIME RECEIVED TIME OF ARRIVAL <br /> TIME OF DEPARTURE <br /> � <br /> PERSONS AT SCENE (TOA) (TQD) <br /> NAME AGENCY p=,ONE NQ. <br /> � /C/u/ ✓��� f'�-c`Y TOA TOD <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> Sc�rA v frCL` <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS <br /> �LiQUID { ] GRANULE <br /> REFERRALS TO: <br /> DATE MAILED: <br /> DATE COMPLETED: PROP 65 -PUAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRES5 <br /> PHONE NO. <br /> "PERSONAL TOJQC SUBSTANCE EXPOSURE RECORD, COMPLETED? C 1 YES <br /> NO <br /> E.R.BINDER COPIES: <br /> I-KSHORT-TERM ATTACHED ON TOP NARRATIVE [1 ANALYTICAL,DATA -+ PROP 65/UAR <br /> C ] EXPOSURE RECORD [] MANIFEST [ ] CLEANUP FIRM REPORT C] OTHER AGENCY REPORTS <br /> C ] REFERRALS441 <br /> MAP I 1 FILE CREATED <br /> A Division of Sen Joaquin County Health Care services <br /> i <br /> f <br />