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i d <br /> PUBLIC HEALTH SERVICES a .,N <br /> P <br /> " SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION y` <br /> Karen Furst, M.D., M.P.H., Health Officer ., <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 Q�,FORa <br /> 209146$-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM # <br /> PREMISE ADDRESS CITY LAdt ang�Q , <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RP) DBA <br /> RP NAME PHONE ' <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, spill, leak. Fire, or a andoned/dumped material)_—pL&{LrF—A QLl -hAO L- <br /> Q•E.Su <br /> T <br /> TIME RECEIVED .',ars„ Qfv��TIME OF ARRIVAL �'• ern TIME OF DEPARTURE 4IG&fn <br /> --- (POA) (POO) <br /> PERSONS AT SCENE <br /> N64E AGENCY PHONE NO. TOA TOD <br /> (A!mawl <br /> IDENTIFICATION OF MATERIAL. (cHEM[cAL[avmvm) ��£SE L 1=60 „ <br /> SUBSTANCE FORM: [] SOLID (I POWDER [] GAS $.X LIQUH) [] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 qq UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [] YES [] NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP [TgARRA TIVE [] ANALYTICAL DATA [4'VROP 651UAR <br /> [ ] EXPOSURE RECORD [] MANIFEST [] CLEAN UP REPORT [] OTHER AGENCY REPOR'T'S <br /> [ ] REFERRALS [�A'P [ ] FILE CREATED <br /> EH 22 014 4/96 <br /> A Division of San Joaquin County Health Care Services <br />