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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY Y' <br /> ENVIRONMENTAL HEALTH DMSION <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 /> i�� , r,, EMERGENCY RESPONSE RECORD <br /> DATE NIf,1 rUC 12�.2 - - SHORT TERM# WOO 1 593 -- <br /> PREMISE ADDRESS 1' SDn CITY - - <br /> DBA I j Y1 K We!r M1k2 <br /> PREMISE OWNER <&(KL - _ PHONE "'- <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT 1r.QX rL4. YA PHONE. <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill, leak, fire,or abandoned/dumped material) <br /> :R er awat �SaI 12D b&t <br /> SfI AAAL Ode 4 <br /> TIME RECEIVED -It? : f TIME OF ARRIVAL 0•5�M TIME OF DEPARTURE 4 M _- <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> N k wl A <br /> II <br /> r . h <br /> IDENTIFICATION OF MATERIAL(CHEMICAL NVOLM) dAC <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS I OILIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PleOP65 W Z ,Z.= ___ UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME Al2DRESS P I�NE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. <br /> BINDERPIES: �• <br /> SHORT-TERM ON TOP 4 NARRATIVE ❑ ANALY'T'ICAL DATA ROP 65/UAR <br /> ❑ EXPOSURE RECORD .MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRAL MAP JR1ILE CREATED <br /> EH22014rev.doe A Division of San Joaquin County Health Care Services 6114/1999 <br />