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PUBLIC HEALTH SERVICES 'Op0„Ulry <br /> f= <br /> SAN JOAQUIN COUNTY 2: � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 `'FSR <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE %/ /� SHORT TERM# <br /> PREMISE ADDRESS �7,���(—• �{% �� CITY <br /> DBA <br /> PREMISE OWNER 13, 1. • ✓_ , 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,)eak, tire,or abandone dumped material) <br /> Ad <br /> TIME RECEIVED - i TIME OF ARRIVAL TIME OF DEPARTURE —?-'196157 <br /> PERSONS AT SCENE <br /> NAME—) AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE/ <br /> REFERRALS TO DATE MAILED �� Y <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD” COMPLETED? ❑ YES Cl NO <br /> `:. BINDER COPIES: <br /> ASHORT-TERM ON TOP NARRATIVE 13ANALYTICAL DATA 11PROP 65/UAR <br /> EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS �bIAP _ ❑ FILE CREATED <br /> A Division of San Joaquin Count: Health Care Services <br />