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PUBLIC HEALTH SERVICES <br /> Oj,O.H'N_ C <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION . <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 304 E.Weber Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 <br /> 209/468-3420 ci a a a <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DDD 8' DATE���� -f- SHORT T/-ERM#��5� <br /> PREMISE /� <br /> ADDRESS % //o S ( (1+/ S�� CITY S fn G KY�^— <br /> DBA &0;_- V� . J&Z S \ <br /> PREMISE OWNER . R • Tu 1�fq S (.11p U. S ( YIDS S_1PHONE <br /> OWNER'S ADDRESS <br /> FACIIJTY CONTACT A 1 lllc Va, rro PHONE <br /> NATURE OF C� j <br /> OMP � Cexplion,spill, le* fire. or abandoned/dumped material) <br /> l /4(t�/ l �/A(/ Yti�YVLK1.! n AL 1 A<- <br /> TIME RECEIVED 1.'--3 O TIME OF ARRIVAL I.` 'TS TIME OF DEPARTURET. 5 <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> Z <br /> U. <br /> pt <br /> hF S :: b r — <br /> S Phf <br /> r>t.. <br /> e-" —c'xyd tr�- <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID ( I POWDER [] GAS LIQUID [ 1 GRANULE <br /> REFERRALS TO: DATE MAILM: <br /> DATE COMPLETED: PROP 65 % 9 / Co UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> L I <br /> ,L Frs� f2 ) �v�e c o vzn JA.0 D 1� <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [1 YES NO <br /> E.R.BINDER.COPIES: <br /> [ ] SHORT-TERM ATTACHED ON TOP [ I NARRATIVE [I ANALYTICAL DATA [ 7 PROP tis/UAR <br /> [ l EXPOSURE RECORD [ I MANIFEST [I CLEANUP FIRM REPORT C l OTHER AGENCY REPORTS <br /> [ l REFERRALS [ ] MAP [] FILE CREATED <br /> A Division of San Joaquin County Heaith Cam Services <br />