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PUBLIC HEALTH SERVICEUrN <br /> �O. .co <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer1, �P <br /> 304 East Weber Avenue,Third Floor • Stockton., CA 95202 �rxoar' <br /> 209/468-3420 <br /> 1 EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM#i� *7 <br /> PREMISE ADDRESS l 7 CITY <br /> DBA <br /> PREMISE OWNER )l�? / PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT !;)U2 PHONE <br /> RESPONSIBLE PARTY(RP)DBA � ` _ <br /> RP NAMEf?6 /217 ✓ ✓� l PHONE - <br /> RP ADDRESS �G� 1< <br /> RP CONTACT }[ J_ [I 4alx , //a' !!/�1 PHONE <br /> NATURE OF OMPLAINT(explosi n, spill, leak, fire,or a'�i ndonedldumped material) l <br /> G 7� <br /> �Po � � C G,��h� <br /> TIME RECEIVED C I.S" TIME OF ARRIVAL S �� S U TIME OF DEPARTURE - v <br /> PERSONS AT SCENE <br /> NAME ✓ AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(ci[EMICALINVOL.VED) �L L i <br /> SUBSTANCE FORM ElSOLID ❑ POWDER CE] GAS LIQUID CC] GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME <br /> ADDRESS_ PHONE <br /> � - <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> +E. R.BINDER COPIES: I <br /> ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 651 UAR / <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS ❑ MAP ❑ FILE CREATED I <br /> EH22014rev.dac A Division of San Joaquin County Health Care Services 6/14/1995, <br />