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PUBLIC HEALTH SERVICES <br /> SAM JOAQUIN COUNTY ` °Z <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 c"QFoa4�' <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> )RTE SHORT TERM 4 <br /> 'REMISE ADDRESS 6717 PrYMniau nRTVV CITY emnrRTnNT <br /> )DAMnTEL <br /> ::REMISE OWNER mot, cry PHONE ( 71a �7n7_�,RR7 <br /> tVNER'S ADDRESfqC,iz,1 nt ➢nrr nc vAouwnv cTF r,00 RALL71S TX :15?40 - <br /> :ACILITY CONTACT TAR g'd _- PHONE ( 2g9) n c ,�— <br /> RESPONSIBLE PARTY (RP) DBA <br /> .2P NAME PHONE <br /> -.P ADDRESS PHONE <br /> :tP CONTACT <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped =t:rial) <br /> C'T ANT)FSTTNF DRiir T Fy -Tr, PIKE <br /> I2v4E RECEIVED n741 i-,n„rc TIME OF ARRIVAL 1 Fnn r.,urs TIME OF DEPARTURE <br /> CrOA) CSOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> IDENTIFICATION OF MATERIAL itR�ICALIWOLV l SOLVENT DENATURED ALCOHOL CAUSTIC, EPHEDRINE <br /> ;UBSTANCE FORM: $1 SOLID [ j POWDER [ 1 GAS (A LIQUID 11 GRANULE <br /> ZEFERRALS TO: DATE MAILED: <br /> '-ATE COMPLETED: PROP 65 8/7/96 UAR <br /> 'ERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> ?ERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES [ DC NO <br /> c. R. BINDER COPIES: <br /> [X] SHORT-TERM ON TOP 1 NARRATR [ 1 ANALYTICAL. DATA b(J PROP 65/UAR <br /> '] EXPOSURE RECORD j MANIFE [ ] CLEAN UP REPORT [ ] OTHER AGENCY REPORTS <br /> 1 REFERRALS [ I MAP ( ] FILE CREATED <br /> cH '-1 014 4/96 <br /> A Division or San Joauuin Cour.�He-lith Care Ser:ices <br />