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PUBLIC HEALTH SERVICES <br /> Rq U i!y <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 �9C,�Q'��`p <br /> 2091468-3420 <br /> 12/26/96 EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM# d)00'-7-43-4 <br /> PREMISE ADDRESS 710 N AMERICAN CITY STOCKTON <br /> DBA DEPART <br /> PREMISE OWNER STATE OF CALIFORNIA PHONE <br /> OWNER'S ADDRESS <br /> FACII,ITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RPS DBA UNKNOWN <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT __ s lam, PHONE <br /> NATO�5�G�ALLO�"OF GA50LINE� or <br /> IN ED <br /> -- CTJY_ QF �C;JQC.KTaN PuBLTc wt)RxS_To C1,EAV TM <br /> TIME RECEIVED 1319 HOURS TIWIS OF ARRIVAL TASE OF DEPARTURE <br /> CrOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME &MLCY PHONE NQS TOA <br /> IDENTIFICATION OF MATERIAL teawu.ntvoLVz i GASOLINE <br /> SUBSTANCE FORM: (] SOLID [] POWDER [I GAS I LIQUID [I GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 12/26/96 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS Edd NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [] YES [] NO <br /> E. R. BINDER COPIES: <br /> (] SHORT-TERM ON TOP [I NARRATIVE [] ANALYTICAL DATA [] PROP 65MAR <br /> (] EXPOSURE RECORD [] MANIFEST [] CLEAN UP REPORT [] OTHER AGENCY REPORTS <br /> [I REFERRALS (I MAP f I FILE CREATED <br /> EH 22 014 4146 <br /> A Division of San Joaquin County Health Care Services <br />