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PUBLIC HEALTH SERVICE51OPQIS!!v .0 <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 /> 2091468-3420 j <br /> ` nnMLERGENCY RESPONSE RECORD f I <br /> 4 <br /> DATE ` �V SHORT TERM 0 _W 0 C) L :3 I 0 <br /> PREMISE ADDRESS -iLa(A CITY_ j `jjV'D <br /> DBA CV- r S <br /> i, <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS f. . <br /> FAC ELITY CONTACT E; Cam PHONE ',,n/ - 5ra a�2S_X Z-71)RESPONSIBLE PARTY (RP) DBA vA N1av t 11`� <br /> RP s CO C _: PHOE` 2 1"7 r 2 <br /> RP?.DDRESsk 1r J L% <br /> RP CONTACT ;m 11lN[� n _ PHONE <br /> NATURE OF COMPLAINT (explosion, spill, leak• -ire, or abandoned/dumped material) <br /> r7 ` <br /> TIME RECEIVED! ►'� TIME OF ARRIVAL 0 P/0 _ TIME OF DEPARTURE 250 PM <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE ' TOA TOb <br /> J 6W: . Mo a - LrLhAlnio EzW !gr-A-23,31 M <br /> a S5f5- Sa- . r� h <br /> IDENTIFICATION OF MATERIAL(CHS.MICALUNVOLVED) <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 /> <br /> <br /> <br /> E. R. BINDER COPIES:/Er �. <br /> SHORT-TERM ON TOP Z__,NARRATIVE ❑ ANALYTICAL DATA L4TPROP 65 ! UAR <br /> ,EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT Cl!OTHER AGENCY REPORTS <br /> E7 REFERRALS ,-MAP ❑ FILE CREATED <br /> A Divi;ior:of San Joaquin Coun.r Health Care=ervices <br /> 'I, <br />