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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DMSION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 �rFbn <br /> 209/468-3420 <br /> ��` EMERGENCY RESPONSE RECORD M 2 <br /> DATE WA(-t^Ah2 0W SHORT TERM # toR-3 <br /> PREMISE ADDRESS -AC= M550n �OQL� CITY -rKaO L <br /> PREMISE OWNER SQt.-c�n✓VIn,.Q-�/ PHONE l'f�l 9—;55- I qtpp <br /> 1 <br /> OWNER'S ADDRESS 1.LAU J <br /> FACILITY CONTACT ICU✓LJ, Wy n ' ' ' I^ PHONE �ZD�IJg35— DU�U10 <br /> RESPONSIBLE PARTY(RP) DBA 5a4/I.JOaQ I. A*t ;Rale}' Cttk b <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> 2 worms -ffir Aly Z ver 6wO s a,i R rez LA ?,D b&+ s a)a re <br /> ��r� c�.t:�s>✓I -Pu,t.Q oyt. �Yt,¢ �'a.�s . <br /> TIMERECEIVED TIMEOFARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> � <br /> <br /> <br /> Wy-(A, ►law Rig rCln�b 8�5- l�i(o�1 ►SIR Wilk <br /> IDENTIFICATION OF MATERIAL icxEuau INVOLVED) Q <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑� GAS LIQUID 13 GRANULE <br /> REFERRALSTOt An O.bV"VnIgst6ne.✓S VTTIce, DATE MAILED <br /> DATE COMPLETED........PeOP65 MO Zg.Wt�0 UAR <br /> PERSONS EXPOSED and/or INIURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. BLNDER OPIES: �• ,_,/ <br /> SHORT-TERM ON TOP 4n NARRATIVE 11 ANALYTICAL DATA ;3 PROP 65/ UAR <br /> ❑ EXPOSURE RECORD .MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS ,ErMAP J�tILE CREATED <br /> EH22014rev.doc A Division of San Joaquin County Health Care Serviccs 6/14/1999 <br />