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PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />DATE <br />PREMISE ADDRESS_ <br />DBA <br />PREMISE OWNER _ <br />OWNER'S ADDRESS <br />FACILITY CONTACT <br />RESPONSIBLE PARTY <br />RP NAME <br />RP ADDRESS <br />RP CONTACT <br />NATURE OF COMPLA <br />SHORT TERM #. <br />CITY <br />�qutN <br />• : CC <br />INT (ex losion, spill,leak fire, or abandonedldumped material} <br />PHONE <br />PHONE / % �S C -- <br />TIME RECEIVEDTIME OF A RRIVALZ,()14y0 TIME OF DEPARTURE U <br />PERSONS AT SCENE <br />NA E GENCY, PHONE TOA TOD <br />IDENTIFICATION OF MATERIAL (CHFN77caL:Yv0LVW) <br />SUBSTANCE FORM ❑ SOLID El POWDER C1 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 0 PROP 65 1 UAR <br />❑ EXPOSURE RECORD ❑ ANIFEST ❑ CLEAN UP REPORT OTHER AGENCY REPORTS <br />❑ REFERRALS �AP ❑ FILE CREATED <br />EH22014rev.doc ADivision of San Joaquin County Health Care Services 6/14/1999 <br />