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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH-DIVISION <br /> Karen Furst, M.D., M.PH., Health Officero-.. <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 ��rFORa` <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD /1�)�) <br /> DATE l SHORT TERM# <br /> PREMISE ADDRESS _L%� /�/U' CITY <br /> DBA <br /> PREMISE OWNER __ PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT <br /> A f A. PHONE <br /> RESPONSIBLE PARTY (RP)DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CON'T'ACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED ��`� TIME OF ARRIVAL �� �Cry TIME OF DEPARTURE S <br /> PERSONS AT SCENE <br /> NAME AGENCX PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS 7LtiQU.ID ❑ GRANULE <br /> REFERRALS TO BATE MAILED <br /> DATE COMPLETED........PROP 0 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> y0EXPOSURE <br /> . BLNDER COPIES: <br /> HORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA PROP 651 UAR <br /> RECORD ❑ ANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS XAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Cate Services 6/14/1999 <br /> EH22014rev.doc <br />