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PUBLIC HEALTH SERVICES �p4RIt!N...... <br /> . <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 /> EMERGENCY RESPONSE RECORD 0006 a / CI <br /> DATE Abe-) SHORT TERM# b <br /> PREMISE ADDRESS 60416 CITY <br /> DBA f e4neadv <br /> PREMISE OWNER / PHONE <br /> OWNERS ADDRESS ®O Sd7,� ,• ( N!/ dp yf r— <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED• 1,Q TIME OF ARRIVAL �= b U TIME OF DEPARTURE l,Y ' V d�e <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> ;DLAiu>y &P_>, l4QS mvb 639-7L7G <br /> IDENTIFICATION OF MATERIAL(caamic wvmvao) 00/4/07.1y <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E.R. BINDER COPIES: AAP <br /> SHORT-TERM ON TOP ARRATIVE 11ANALYTICAL DATA ElPROP 65/UAR <br /> EXPOSURE RECORD ANIFEST 11CLEAN UP REPORT ElOTHER AGENCY REPORTS <br /> 13REFERRALS ❑ FILE CREATED <br /> EH22014rev.doc A Division of San Joaquin County Health Care Services 6/14/1999 <br />