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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 445 N. San Joaquin Street • P.O. Box 388 0 Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> 1` :f EAdERGENCY RESPONSE RECORD <br /> DISTRICT# DATE J/ �r�SHORT TERM # <br /> PREMISE ADDRESS CITY5"' ca <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT �j^'P�'^�'�' PHONE <br /> NATURE OF COMPLAINT (expf6sion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER ] GAS UID [ l GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E.R.BINDER COPIES: <br /> [ ] SHORT-TERM ATTACHED ON TOP [ ) NARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> f ] REFERRALS [ ] MAP [ ] FILE CREATED <br /> A 1)i%ision of San Joaquin County Health Care Services <br />