Laserfiche WebLink
i <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENYIRONINIENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto. M.D., M.P.H., Acting Health Officer <br /> �[4iCRt� <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> { <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE to`(7- I SHORT TERM# <br /> PREMISE ADDRESS SG✓1 Tepee L*r 1 1f P.r 1 L-trn S CITY � J <br /> — Y <br /> .k <br /> DSA <br /> PREMM OWNER <br /> PHONE�, _.-- PHONE '� <br /> OWNER'S ADDRESS �� r <br /> FACILITY CONTACT rn LG PHO 7 <br /> NATURE OF COMPLAINT CeXplosion, spill,lmi4 fie, or abandoned/dumped material) <br /> �R.-�' <br /> rslvlE RECEIVED_ a, �o� tv, . TRZ-:OF ARRIVAL 440 g.✓Y�• TIME OF DEPAR'T'URE �% ��P.ry� • _ <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCv PHONE NO. TOA TOD <br /> d u s Na <br /> <br /> i <br /> f <br /> IDENTIFICATION OF MATERIAL (CHEMICAL. IrVOLVED) <br /> SUBSTANCE FORM: [) SOLD [] POWDER [ 7 GAS j�LIQUM [ ] GRANULE <br /> t4 <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 q`T UAR <br /> - 1 <br /> PERSONS EXPOSED and/or INJURED <br /> NAME .ADDRESS s PHONE NO. <br /> i <br /> "PERSONAL'TOXIC SUBSTANCE EXPOSURE UCORDR COMPLETED? [ I x YES NO <br /> i <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ATTACHED ON TOP` *-%4tRATWE [ I ANALYTICAL DATA PROP 65/UAR <br /> I l EXPOSURE RECORD [-.MANIFEST [) CLEANUP FIRM REPORT -OTHER AGENCY REPORTS l <br /> [ ] REFERRALS C ] FILE CREATED us Nav+ <br /> WCaas+ Gc Ar. <br /> a:� nivn of San Joaquin County Health Cure Services <br />