Laserfiche WebLink
{ PUBLIC HEALTH SERVICES <br /> C, <br /> SAN JOAQUIN COUNTY 'o.� a <br /> t ` ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 clog <br /> 2091468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM # <br /> PREMISE ADDRESS CITY # <br /> DBA -- <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY.CONTACT PHOS <br /> I. <br /> RESPONSIBLE XARTY (RP) DBA <br /> RP NAMEPHONE , <br /> RP ADDRESS <br /> RP CONTACT PHOr4E ; <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire,,or a andoned/dumped material) �.. (L�,cL _ �Orl 4AA L- <br /> Ilpu{ <br /> .y� I <br /> TIME RECEIVED Co'.Dtl. QM. TIME OF ARRIVAL (v'. F'! Q TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> N E AGENCY PHONE NO. TOA TOD <br /> �1 Wevowl <br /> I � <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) 'T:�-LjEl <br /> SUBSTANCE FORM: [] SOLID [ ] POWDER [] GAS LIQUID [] GRANULE <br /> f REFERRALS TO: DATE MAILED: , <br /> DATE COMPLETED: PROP 65 UAR <br /> - s <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> T <br /> i <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [] YES [] NO <br /> E. R. BINDER COPIES: <br /> V HORT-TERM ON TOP [4-gAiQ THE ( ] ANALYTICAL DATA ( ROP 65/UAR { <br /> [] EXPOSURE RECORD [] MANIFEST [] CLEAN UP REPORT (] OTHER AGENCY REPORTS <br /> [] REFERRALS 11'1;IAP [] FILE CREATED <br /> EH 22 014 4/96 <br /> A Division of San Joaquin County Health Care Services <br />