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• '4 <br /> PUBLIC HEALTH SERVICES <br /> SAIi JOAQUIN COUNTY <br /> ENVIRON-IENTAL HEALTH DIVISION ` <br /> Ernest M. Fujimoto.M.D., M.P.H., Acting Health Officer <br /> -*C/FORe► <br /> 445 N. San Joaquin Sit • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE 3-17-4q /ISH..ORT TERM# <br /> PREMISE ADDRESS 12- CITY <br /> DBA <br /> PREMISE OWNER 1 J C)V-yj� e-e- PHONE �20ri) ;6�04—D7`ja <br /> OWNERS ADDRESS ,1490n W <br /> FACIIITY CONTACTy J O V_,_Q. G�—n,--rJ Ppyw of PHONE (ZCft) 44-01 <br /> NATURE OF COMPLAINT (explosion,spill,lmzk tee,or abandoned/dumped matmial) <br /> TIME RECEIVED I 1: TBEE Cr ARRIVAL 12:aD Tl'�- OF DEPARTURE 3 :20 <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCr PHONE NO. TOA TOD <br /> C,P+ pr v '4 • P OtA-j -'A frAScsiaan De4.1rira bts4e cF <br /> Frc.n •Qv z� tcno�J 3.00 <br /> �t-,� t>Sht oI�GL O"tu eP erJtca <204 y44-�4 uln >3:00 M <br /> SO 5 3h Cm.w�c (ZeAl 339 $24 73:00 PM <br /> I twt Cc, ? 3:00 prt <br /> ^v-tna �{ct•z (�CtGchn.w✓tt' catcCSto)24�? 38 7 3saD PM <br /> to I)tt+.k 5t. 8td LIEBE Corw-o C-4 ':N60-60b <br /> IDENTIFICATION OF MATERIAL (CHEl CAL MMVED) Cr)Ct SC)(l n-- <br /> SUBSTANCE FORM: C-3 SOLID [] POWDER [ l GAS Gam= <br /> R.ERRAIS TO: G DATE MAILED: <br /> DATE COMPLETED: PROP 65 �'2.�'-l� UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> -PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? C ] YES [] NO <br /> E.R.BINDER COPIES: <br /> 1,/SHORT-TERM ATTACHED ON TOP [�TNE [] ANALYTICAL DATA C /PROP 65/UAR <br /> C 7 EXPOSURE RECORD C 1 YA� C ] CLEANUP FIRM REPORT C] OTHER AGENCY REPORTS <br /> C ] REFERRALS r VX [] FILE CREATED <br /> a.i.ion or Sun Joaquin Countv Hralth CareSrnirn <br />