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t <br /> PUBLIC HEALTH SERVICES ,QP.�U�N.,CO <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION " <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 4`'F 6 5st <br /> 209/468-3420 <br /> �C EMERGENCY RESPONSE RECORD <br /> DATE `OCA - SHORT TERM# L ✓ I <br /> PREMISE ADDRESS l ry P5aPl WL CITY Vc T O C- <br /> DBA Com(( Q�ZZ <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RP) DBA (, �„„�g7�>-►-�. <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, tire, or abandoned/dumped material) <br /> IC V <br /> TIME RECEIVED TIME OF ARRIVAL R ./O TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> rr / <br /> M � h. <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM /I❑ SOLID 11 POWDER ❑ GAS LIQUID E] GRANULE <br /> REFERRALS TO h + V t&- «" DATE MAILED <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP dNARRATIVE ❑ ANALYTICAL DATA �'PROP 66 /UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS &MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />