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PUBLIC HEALTH SERVICES <br /> o?o.0 rw c <br /> �. �.: .o <br /> SAN JOAQUIN COUNTY 2:. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer 3 - <br /> 304 E.Weber Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 �QC1Fa.p+ r <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT # DATE Z- Z-�6. SHORT TERM# �eL <br /> PREMISE ADDRESS CITY ku' + <br /> DBA S J/ <br /> ?REMISE OWNER C{e1I PHONE 9/6 - ,37/- 6/2 <br /> OWNERS ADDRESS <br /> FACII.I'PC CONTACT PHONE _4��_ Z <br /> NATURE OF COMPI�IINT (e�q/.'tosion#spffil, e, or abandoned/dumoed material) <br /> 7 UO 3 C1a �L..N�.tl�Le v� O i e.,¢.G z /J� �•-GI - <br /> TIME RECEIVED /O-�5 HT1 TIME OF ARRIVAL // : S IE OF DEPARTURE /r = VO PM . <br /> iOA) (TOD) <br /> ?ERSONS AT SCENE <br /> NAME AGENCY PHONE VO. TOA TOD <br /> M rd-/FfC- 601h- -� <br /> S{.aI/ o--/ <br /> �H / 7 <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) �i�-b e-0 s• Gw,c/ti,e. <br /> SUBSTANCE FORM: [ I SOLID [ ] POWDER [ I GAS [-T'LIQU C ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 Z -`x'16 UAR <br /> PERSONS EXPOSED and/or INJURED ?HONE NO. <br /> NAME ADDRESS <br /> 'PERSONAL TOXIC SUBSTANCE 0POSURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E. R.BENDER COPIES- J <br /> [ SHORT-TERN[ ATTACHED ON TOP [ NARRATIVE C ANALYTICAL DATA (.I/PROP 65/UAR <br /> [ ] EXPOSURE RECORD C ,/�L 11UEST M CLEANURM <br /> PORT FIRM RORT [v7 OTHER AGENCY REPORTS <br /> [ I REFERRALS [ I MAP [ ] FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />