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PUBLIC HEALTH SERVICES <br /> T. N. <br /> - .9 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer �... P <br /> °ciFoa:+ <br /> 304 East Weber Avenue, Third Floor ' Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE f,(,�-tel l C� �,1 SHORT TERLM X �,0 D 016 2.1x4 <br /> PREMISE ADDRESS 1 DDD E • �(l�'Ll ' 'Da CITY F-e,.JC k CAkUQ <br /> DBA <br /> PREMISE OWNER «k*WM POL6-fi rnPHONE q14Z 5-Z7C1 <br /> OWNER'S ADDRESS 100Q <br /> „ E7 Qdl <br /> FACILITY CONTACT-M Vt.10-CVrSCDAPHONE <br /> RESPONSIBLE PARTY (RP) DBA <br /> PHONE <br /> RP NAME <br /> RP ADDRESS <br /> PHONE <br /> RPCONTACT <br /> NATURE OF COMPLAINT(explosion. spill, leak, tire. or abandoned/4umped material) <br /> t n� uMd <br /> TIME RECEIVED 3.�_ TIME OF ARRIVAL W.30AM TIME OF DEPARTURE '&00A” <br /> PERSONS AT SCENEAGENCY PHONE TOA TOD <br /> NAME <br /> ull"Is AcLi cc Mor a,/ nv ✓ - <br /> D <br /> �cw�Jc�c I�San U P a d �U c� oo� <br /> IDENTIFICATION OF MATERIAL. wvoureot UID ❑ GRANULE <br /> SUBSTANCE FORM C1 SOLID ❑ POW R C3 GAS Q <br /> DATE MAILED <br /> REFERRALS TO <br /> DATE COMPLETED........PROP 65 h < UAR <br /> �V(Ydl�. <br /> PERSONS EXPOSED and/or INJURED -ivVKUk PHONE <br /> NAME ADDRESS <br /> "PERSONAL TOXIC SUBS EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> R'SHORSU E R ON TOP NARRATIVE S 0 ANALYTICAL <br /> UP REPORTA ❑ OTHER AGENCY REPORTS <br /> ❑ EXPOSURE RECORD []FILE CREATED <br /> ❑ REFERRALS �'°`P - <br /> A Division of San Joaquin Counn' Health Care :ercices <br />