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W001 2362 <br /> PUBLIC <br /> HEALTH SERVICES )�POUalc�.C�G <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D.,M.P.H., Health Officer c;Foa <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> ` EMERGENCY RESPONSE RECORD <br /> r�„w-e l OL SHORT TERM 1l <br /> DATE . CITY L _ " Q•'� <br /> PREMISE ADDRESS � � <br /> DBA PHONE <br /> PREMISE OWNER <br /> OWNER'S ADDRESS PHONE <br /> FACILITY CONTACT �~ <br /> RESPONSIBLE PARTY(RP)DBA PHONE <br /> RP NAME <br /> RP ADDRESS PHONE <br /> RP CONTACT <br /> NATURE OF COMPLAINT(explosion, spill,leak,fire,or bandonedldum�material) ` - , ' � <br /> 6 "zTcq•, ulL <br /> TIbIE OF ARRIVAL_le � TIME OF DEPARTURE <br /> TIME RECEIVED t� IOD <br /> PERSONS AT SCENE AG NCY <br /> PHTOA _OD <br /> ONE <br /> NAME <br /> IDENTIFICATION OF MATERIAL�u�wcwL 14V V60) <br /> '2 ❑ GAS ILLIQUID [3 GRANULE <br /> SUBSTANCE FORM C1 SOLID [I POWDER <br /> DATE MAILED <br /> REFERRALS TO UAR <br /> DATE COMPLETED........PROP 65 <br /> PERSONS EXPOSED and/or INJURED PHO <br /> AD^ DRESS <br /> NAME <br /> EXPOSURE RECORD" COMPLETED? <br /> ❑ YES <br /> ❑ NO <br /> 'PERSONAL TOXIC SUBSTANCE <br /> R.BINDER COPIES: ❑ A LYTICAL DATA ❑ PROP 65!UAR <br /> TARP-FAr ❑ OTHER AGENCY REPORTS <br /> SHORT-TERM ON TOP /❑ MANIFEST CLEAN UP REPORT <br /> !❑ EXPOSURE RECORD ❑ MAP ❑ FILE CREATED <br /> El REFERRALS <br /> A Division of San Joaquin County Health Care Services <br />