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FILE COPY <br /> PUBLIC HEALTH SERVICES >p°4SA <br /> SAN JOAQUIN COUNTY <br /> ENVIROhI- IENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer ; Y.. <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> DISTRICT# Oq� DATE 111'31q67 EMERGENCY RESPONSE RECORD <br /> SHORT TERM# <br /> PREMISE ADDRESS �CC) �(��I I.Si-F'�(Q Q P(]r-k. <br /> DBA �► 1(1A� ���r{q'�y/+fGS s p <br /> PREMISE OWNER PHONE <br /> I <br /> OWNER'S ADDRESS O <br /> FACILITY CONTACT Bi 17x1 CL PHONE <br /> N/�ATURE OF COMPLAINT(explosion, spilt, Irk,fire, or abandoned/dumpedmat ) <br /> ` flv�nLs-na+`i o,n <br /> I L <br /> 3S <br /> TIME RECEIVEDTIME OF ARRIVAL TIME OF DEPARTURE 10 30 <br /> PERSONS AT SCENE TOA) tTCDj <br /> NAME AGENCY PHONE NO. TOA TOD <br /> Milo. ; bi=rlHfeR xng irr Sea �a IOjaow <br /> milt �r-1C� r `/IM FD 2g'A Sr.�'� ?n See n ln�n <br /> lnd Perm/-- CR76-4,/3 ayl <br /> IDENTIFICATION OF MATERIAL (CHEMICAL IYYOI.VED ham' <br /> ��// ) <br /> SUBSTANCE FORM: dl SOIJD [] POWDER [ ] GAS L41QUID [ ] GRANULE <br /> REFERRALS TO:_ A(/i8- DATE MAILED: <br /> DATE COMPLETED: PROP 65��/�/Qej UAR <br /> <br /> <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD, COMPLETED? X YES [ ] NO <br /> E.R.BINDER COPIES: <br /> [ I SHORT-TERM ATTACHED ON TOP [] YARRATIVE [ 7 ANALYTICAL DATA [ ] PROP 65/UAR <br /> [I EXPOSURE RECORD [I MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ I REFERRALS [7 ]IAP [ ] FILE CREATED <br /> i Nll,nn of Sun Joaquin Count., Health Care Service. <br />