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PUBLIC HALTH SERVX ES <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 />209/468-3420 <br />DATE <br />PREMISE A <br />DBA <br />PREMISE 0 <br />OWNER'S ADDRESS <br />FACILITY CONTACT <br />EMERGENCY RESPONSE RECORD WW 1�/a2 <br />,rr f SHORT TERM # <br />I Li 11 4 4 ti + CITY c;.r <br />�c, <br />RESPONSIBLE PARTY (RP) DBA <br />RP NAME <br />RP ADDRESS <br />RP CONTACT <br />NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br />Lo <br />PHONE <br />PHONE <br />PHONE <br />PHONE <br />TIME RECEIVED %-WA wi TIME OF ARRIVAL Q! 0 2 TIME OF DEPARTURE <br />PERSONS AT SCENE <br />NAME AGENCY PHONE TOA TOD <br />IDENTIFICATION OF MATERIAL {CHEMICAL INVOLVED) <br />SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br />REFERRALS TO L DATE MAILED <br />DATE COMPLETED ........PROP 65 4 fi'Z— UAR <br />PERSONS EXPOSED and/or INJURED <br />NAME ADDRESS <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES <br />E. R. BINDER COPIES: <br />6JOSHORT-TERM ON TOP PPNARRATIVE ❑ ANALYTICAL DATA <br />❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT <br />17 REFERRALS P MAP ❑ FILE CREATED <br />A Division of San Joaquin County Health Care Services <br />PHONE <br />❑ NO <br />--0 PROP 65 1 UAR <br />❑ OTHER AGENCY REPORTS <br />