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PUBLI HEALTH SERVICES <br /> SAN JOAQUIN COUNTY71 <br /> : <br /> E VIRON-NIENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto. M.D., M.P.H., Acting Health Officer .. �P <br /> hi <br /> 445 <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE SHORT TERM# <br /> PREMISE ADDRESS �YD3 l/� (//�/� CITY <br /> DBA z�/ Gv✓ l//(1L <br /> PREMISE OWNER C/l / � A PHONE Y 3' L27 7 d <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT bre/< PHONE <br /> NATURE OF CO LAINT ( osi Sp fire, or abandon d ped ma <br /> r F/ <br /> TIME RECEIVED / JU TIME OF ARRIVAL / TIlVIE OF DEPARTURE Z <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME � GENCY PHONE NO. <br /> TOA TOD <br /> 4 <br /> IDENTIFICATION OF MATERIAL (ClEMI CAL Ib-,AXVED) <br /> SUBSTANCE FORM: [] SO [J POWDER [ ] GAS LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or IN <br /> NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE OSURE RECORD' COMPLETED? [ ] YES [ ] NO <br /> E.R-BINDER COPIES: <br /> SHORT-TERM ATTACHED ON T PYARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> 14 <br /> [ ] EXPOSURE RECORD [] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS MAP [ ] FILE CREATED <br /> a D-i.ion of San Joaquin County Health Care Service <br />