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f . <br /> PUBLIC 1-.,ALTH SERVI@,7S paV!!V <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE 5 SHORT TERM# <br /> PREMISE DDRESS _ G J "J CITY <br /> DBA <br /> PREMISE OWNERPHONE �J Ub�Cl <br /> OWNER'S ADDRESS <br /> FACILITY CONTACTy t' PHONE <br /> RESPONSIBLE PARTY (RP) DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAI>j(explosion, spill, leak, tire, or abandoned/dumped serial) <br /> G <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NA E AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM 9 <br /> �❑ SSC3OLID POWDER GAS ❑ LIQUID ❑ GRANUL/ <br /> REFERRALS TO (/?e- 0-�//1- DATE MAILED 40 <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> Di-XZ42;Z-4 / <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED'? ❑ YES ❑ NO <br /> E./R. BINDER COPIES: <br /> tI SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 65 <br /> ❑ <br /> il EXPOSURE RECORD CI ANIFEST ❑ CLEAN UP REPORT C3 OTHER AGENCY REPORTS <br /> a— REFERRALS Lel MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />