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} <br /> 'oPQ co . <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY a Z <br /> ENVIRONMENTAL HEALTH DIVISION • <br /> l Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 ' ro <br /> i 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM# COO <br /> PREMISE ADDRESS zk a"C> CITY 1 <br /> DBA 4/ <br /> PREMISE OWNER 4s-vcrGe PPHONE r" Z-46'-.3 7'Pe- <br /> OWNER'S ADDRESS /G <br /> FACILITY CONTACT =17 G4 ✓4/, -PHONE <br /> RESPONSIBLE PARTY (RP) DBA Ass'v✓e— <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, ak, fire,or abandoned/dumped material) tie -ry <br /> TIME RECEIVED TIME OF ARRIVAL " l! I Zane TIME OF DEPARTURE ' p <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> I <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: (] SOLID [] POWDER (] GAS NoOLIQUID (] GRANULE <br /> REFERRALS TO: 4M DATE MAILED: IVIA- <br /> DATE COMPLETED: PROP 65 1 UAR fiA <br /> PERSONS EXPOSED and/or INJURED <br /> N ADDRESS PHONE NO. <br /> e <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [) YES [] NO <br /> E.R.BINDER COPIES: <br /> [] SHORT-TERM ON TOP [) NARRATIVE [) ANALYTICAL DATA [] PROP 65/UAR <br /> [) EXPOSURE RECORD. [] MANIFEST () CLEAN UP REPORT [) OTHER AGENCY REPORTS <br /> j [] REFERRALS [] MAP [J FILE CREATED <br /> EH 22 014 4/96 <br /> A Division of San Joaquin County Health Care Services <br />