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PUBL C HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DIVISION ` <br /> Ernest . Fujimoto, M.D., M.P.H., Acting Health Officer •. p <br /> qL/FOR�a� <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> /6/ EbE RGENCY RESPONSE RECORD <br /> DISTRICT# DATE SHORT TERM# <br /> PREMISE ADDRESS !x/03 �/� �l/� Crit <br /> DBA <br /> PREMISE OWNER C/i' / PHONE <br /> OWNER'S ADDRESS cfi <br /> FACILITY CONTACT CJ-� / v/ PHONE <br /> NATURE OF CO LAINT ( osi q sp fire, or ahwndoneqVdped ma <br /> TIME RECEIVED TIKE OF ARRIVAL 9 / TIME OF DEPARTURE f Z <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME <br /> [- <br /> CY n GENPHL _ TOA TOD <br /> 9 <br /> IDENTIFICATION OF MATERIAL (t MICAL IWYOLVED) <br /> SUBSTANCE FORM: [] SO [] 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 EXP SURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E-R.BINDER COPIES: <br /> SHORT-TERM ATTACHED ON T --4`AiRRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS --KMAP [ ] FILE CREATED <br /> a D-ision of San Joaquin County Health Care Service. <br />