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J <br /> PUBLIC HP*ALTH <br /> 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 /> 2091468-3420 <br /> �- 11— <br /> EMERGENCY RESPONSE RECORD <br /> DATE co SHORT TERM#_ C U �r) <br /> PREMISE ADDRESS ft)-ZZ �7(-O l -Gi — CITY CqOA <br /> DBArc <br /> PREMISE OWNER t PHONE <br /> OWNER'S ADDRESS J' `f:� <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP) DBA ��~ C - '� D L li d-t F <br /> RP NAME j " ,,yy f PHONE <br /> RP ADDRESS { 1 U r L {'�rot c 5 <br /> qq <br /> RP CONTACT PHONE <br /> 'MATURE OF COMPLAINT(explosion, spill, leak, tire, or abandoned/dumped material) <br /> TIME RECEIVED Aug TIME OF ARRIVAL j 10 Ai-x TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOO <br /> nMG 4 Ke Sk A� Ce 1PKS c,- 014-907 <br /> C1-40 <br /> le.d <br /> IDENTIFICATION OF MATERIAL(CHEMICAL:�)ivs <br /> SUBSTANCE FORM E] SOLID POWDER ❑ GAS ❑ LIQUID C1 GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE Q <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 65 / UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS ❑ MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care-Services <br />