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PUBLIC MEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> 2 ':s <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer t <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 `q�;FORa`P <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM 1/ <br /> PREMISE ADDRESS Z—✓�1 I w � � Pa-+ Lzll� CITY <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RP) DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [] SOLID [ ] POWDER [] GAS [] LIQUID [] 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 [I NO <br /> E. R. BINDER COPIES: <br /> ( ] SHORT-TERM ON TOP [J NARRATIVE [] ANALYTICAL DATA [] PROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [] CLEAN UP REPORT [] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ ] MAP [] FILE CREATED <br /> EH 22 014 4/96 <br /> A Division of San Joaquin County Health Care Services <br />