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PUBLIC HEALTH SERVICES �aPQ�tN <br /> o� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION _ <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer • oq,. <br /> 445 N. San Joaquin Street • P.O. Boz 388 0 Stockton, CA 95201-0388 �iiibw <br /> (209) 468-3420 <br /> �/ EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE 1=� I SHORT TERM# <br /> PREMISE ADDRESS S`�oCc'�'nV� lr' ramoCkca,1 IVnC- CITY S!"t�-oao.�c�.-�'Cv�� <br /> DBA S-�vc�.c.�-or. l,1`axS (��oC�a.� ("C. . z5z/ W, �i�QS�'lmA4cyk %i SL. (4t-- F <br /> n <br /> PREMISE OWNER t *6 `-+o� S-t oclt�vn PHONE <br /> r„r G+I C'.L <br /> OWNER'S ADDRESS <br /> FACILITY CONTACf �cS PHONE -41e3- 3280 <br /> NATURE OF CO (explosion,spill, leak, cr abandoned/dumped material) (l <br /> ll 5'C� /o Sodrum /-lydrbxrde so/u/tor OCs�IrltCl du✓<v S O• Q-rf-C� <br /> TIME RECEIVED 9;IfIU a� TIME OF ARRIVAL /U Z9 a. TIME OF DEPARTURE /Z:/C' <br /> (TQA) <br /> PERSONS AT SCENE <br /> NAME ,. AGENCY PHONE NO. TOA TOD <br /> kr�nf l�1(I f.J' yr'OCCTrw r-I rC <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) Cr,druw.. -F ,.reKtc�c� V=.7°S S��ufRa� <br /> SUBSTANCE FORM: C I SOLID [ l POWDER [ ] GAS- 'KLIQUID C ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES [] NO <br /> E.R.BINDER COPIES: / <br /> C ] SHORT-TERM ATTACHED ON TOP 54 NARRATIVE [] ANALYTICAL DATA [ ] PROP 6S/UAR <br /> [] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> l/ <br /> C ] REFERRALS (p7 MAP [] FIE CREATED <br /> A Division of San Joaquin County Health Cam Serviees <br />