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SERVICES <br /> PUBLICaPquLk HEALTH } .ai <br /> SAN JOAQUIN COUNTY „ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> A <br /> Ernest M. Fujimoto, b1.D., M.P.H., Acting Health Officer �lFcA <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> AGENCY RESPONSE RECORD <br /> SHORT TERM# <br /> DISTRICT#1�DATE 9 <br /> CI1Y <br /> PREMISE ADDRESS <br /> DSA <br /> PHONE---------------- <br /> PREMISE OWNER � ��-- <br /> owrrER's ADDRESS 7z4 �alr�it �!��� S�� �D��' <br /> CONTACT en� � U y' � PHONE <br /> FAcnm CONT or abandoned/dumped material) <br /> NATURE OF COMPLAINT Iosian,spill,/lea/k,fire, <br /> S• <br /> Z:exa �, TIME OF ARRIVAL Z'y� TIME OF DEPARTURE <br /> TIME RECEIVED (TOA) (TOD) <br /> PERSONS AT SCENE PHONE NO. TOA LO D <br /> NAME AGENCY Z nci) <br /> � !b <br /> 0 <br /> IDENTIFICATION OF MATERIAL. (c)iEMICAL IWOLVED) <br /> 'KLIQLLID GRANULE <br /> SUBSTANCE FORM: C l SOLID C] POWDER C ] GAS <br /> I ] <br /> REFERRALS TO: DATE MAILED: <br /> ` <br /> DATE COMpIJ;TF.D: PROP 65 ��9`� LIAR <br /> PERSONS DOSED and/or INJURED DRESS PH— ONE NO. <br /> NAME <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? C 7 <br /> YES NO <br /> E.R BINDER COPIES: Q <br /> SHORT-TERM ATTACHED ON TOP _yfNARRATLVE L ] ANALYTICAL DATA PROP 65/UAR <br /> C ] EXPOSURE RECORD C] MANIFEST L ] CLEANUP FIRM REPORT C 1 OTHER AGENCY REPORTS <br /> [ ] REFERRALS A MAP C 7 FILE CREATED <br /> 1, A Di%i%iun of San joayuin County Health Care Service. <br />