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7 <br /> 1 <br /> PUBLIC HEALTH SERVICES �QP�u!N•.0 <br /> . � o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DMSION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> C�;��PORN;P <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD ,) <br /> DATE �DD SHORT TERM# U 00, <br /> PREMISE ADDRESS CITY —— <br /> 1 / <br /> DBA 0 • .C C. <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT 122d rad <br /> PHONE <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE /L� / -7-7Z <br /> RP ADDRESS �0 t;l GC, IC ,v ' <br /> RP CONTACT 4u fC /61--J'/ t �/erl�D� PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED (S �� TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE 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 <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> EH22014rev.doc A Division of San Joaquin County Health Care Services 6/14/1999 <br />