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5 <br /> - PUBLIC HEALTH SERVI <br /> CM <br /> aP c <br /> SAN JOAQUIN COUNTY <br /> E ENVIRONMENTAL HEALTH DWISION ` <br /> Ernest M. Fujimoto, M.D., M.P.H., Actin <br /> � •� g Health Officer � �•.- .� I <br /> j 445 N. Sart Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 4 � <br /> (209) 468-3420 <br /> ;a Q <br /> DISTRICT# DATE ` EIVf MMUCY RESPONSE RECORD <br /> i <br /> _ SHORT TERM# DOo q S^ <br /> PREMISE ADDRESS 7. <br /> DBA <br /> PREMISE O <br />�. PHONE <br /> OWNER'S ADDRESS <br /> i <br /> FACILITY CONTACT j 11 <br />' NA OF OMFLAINT ( on, spill, leak, a daned/dumped tenial PHONE <br /> TIME RECEIVED} , Ta OF ARRNAL ;—3-20A •°' TIME OF DEPARTURE <br /> PERSONS AT SCENE (TOA) (TOD) <br /> NAME AGENCY <br /> PHONE NO. TOA TOD <br /> CHI4 <br /> IDE,=1CATION OF MATERIAL (CHEMICAL 114VOLVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER j ] GASIQUID [ ] GRANULE <br /> REFERRALS TO: \ { <br /> DATE MAILED: <br /> DATE COMPLETED: PROP 65 � 9 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> `F <br /> ' I <br /> I <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES 'F�-\NO <br /> F <br /> E.R.BINDER COPIES: <br /> [`1 SHORT-TERM ATTACHED ON TOP M-NARRATIVE jA ANALyl7[CALDATA [] PROP 65/[TAR <br /> ] EXPOSURE RECORD []'MANIFEST ] CLEANUP FIRM REPORT [] OTHER AGENCY REPORTS <br /> f 1 REFERRALS [ ] MAP [ ] FILE CREATED <br /> 4 <br /> 4 <br /> I <br /> t <br /> A DiNi.siun of.San Joaquin County Health Carr Srrvicr, <br />