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1 0 <br />PUBLIC HEALTH SERVICEI <br />SAN JOAQUIN COUNTY <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 <br />209/468-3420 <br />EMERGENCY RESPONSE RECORD <br />DATE -� ? -L G " ` /� // / SHORT TERM # C� CTa 7 3 /7cl <br />PREMISE DRESS /� C �.JCJU-c�.!' �d (�. CITY �� f <br />DBA -e <br />PREMISE OWNER G -f PHONE -VQ - :7 2.3 <br />OWNER'S ADDRESS 0-41 ��o /0�,--1�ff G4 g c� � , <br />FACILITY CONPHONE SrZ0 -9 7 4 - O 73 <br />RESPONSIBLE PARTY (RP) DBA <br />RP NAME PHONE <br />RP ADDRESS <br />RP CONTACT PHONE <br />NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) s <br />TIME RECEIVED TIME OF ARRIVAL r TIME OF DEPARTURE s0 hy <br />(TOA) (POD) <br />PERSONS AT SCENE <br />NAME AGENCY PHONE NO. TOA TOD <br />d(Rlh L. G)c0344L i, D:cN ( // An <br />n/n/ -e E <br />IDENTIFICATION OF MATERIAL (am4ica.►xvoLvm) /may GY (/. ud iLZ <br />SUBSTANCE FORM: [ ] SOLID [ ] POWDER I GAS <br />REFERRALS TO: <br />r• � r <br />DATE COMPLETED: PROP 65 / Z--,1.6 --14 UAR <br />PERSONS EXPOSED and/or INJURED <br />NAME ADDRESS <br />PHONE NO. <br />[]GRANULE <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" <br />COMPLETED? [ ] <br />YES [ ] NO <br />E. R. BINDER COPIES: <br />[I/SHORT-TERM ON TOP <br />[NARRATIVE <br />[ ] ANALYTICAL DATA <br />PROP 65/UAR <br />[ ] EXPOSURE RECORD <br />[ ] MANIFEST <br />[ ] CLEAN UP REPORT <br />[ ] OTHER AGENCY REPORTS <br />[ ] REFERRALS <br />6[ klkp <br />[ ] FILE CREATED <br />EH 22 014 4/96 <br />A Division of San Joaquin County Health Care Services <br />