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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY r. � <br /> :z <br /> ENVIRONMENTAL HEALTH DIVISION `` <br /> Karen Furst, M.D., M.P.H., Health Officer.. ; <br /> �fFORa <br /> 304 East Weber Avenue, Third Floor - Stockton, CA 95202 <br /> 209/468-3420 <br /> QQ EMERGENCY RESPONSE RECORD <br /> DATE I D -1 0 Z SHORT TERM# <br /> PREMISE ADDRESS d Do �• �� 0Q • CITY L A' LO <br /> DBA fol-) PA-ie.if+ Z. 1 l'DI}� — T�+�v Terni► l <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS r- <br /> FACILITY CONTACT PHONE- `1 Z - J 2 7� <br /> RESPONSIBLE PARTY(RP)DBApHONE Q72 $%Z.— 2-10-7RP NAME � tTJ <br /> RP ADDRESS <br /> PHONE <br /> RP CONTACT <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) a <br /> r�L{.C � ��,} �tn� 00su yL`$ �O'� (�Ki^ ,A �►roN re v <br /> (`QbS►J MSG. W Ar{u^ Ol'itUp 13 k <br /> TIME RECEIVED 3 •D D Gtf'N TIME OF ARRIVAL) , -�� _ TIME OF DEPARTURE <br /> PERSONS AT SCENE PHONE TOA TOD <br /> NAME AGENCY <br /> IDENTIFICATION OF MATERIAL(CtMIAT[AL]NvoLVED) o ❑ GRANULE <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS QED <br /> DATE MAILED <br /> REFERRALS TO <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED PHONE <br /> NAME ADDRESS <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE ORD" COMPLETED? ❑ YES El NO <br /> E. INDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE 13 ANALYTICAL DATA ❑ PROP 651 UAR <br /> EJ EXPOSURE RECORD ❑ N-1AW FEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care Services 6/14/1999 <br /> EH22614rev.doc <br />