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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY = � <br /> ENVIRONMENTAL HEALTH DMSION a <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> ��FORa <br /> 304 East Weber Avenue,Third Floor• Stockton, CA 95242 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE l U -1 0 Z SHORT TERM# <br /> PREMISE ADDRESS 0 DO �, RO aO . _ CITY L A, w <br /> DBA i Pa-L��1 t, +� t'o - T��U Te�r+�►�-o-t <br /> PREMISE OWNER S PHONF, <br /> OWNER'S ADDRESS PHONE Z <br /> ,� �j <br /> FACILITY CONTACT t lJ G L `� <br /> `' <br /> RESPONSIBLE PARTY(RP)DBA &S T TN l efy M of 4-x, - PHONE Q72 <br /> RP NAME t7l-i <br /> RP ADDRESS �RU D T2 x S <br /> PHONE <br /> RP CONTACT <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> A #ru��I ly..,} �f�QJ' N+7SU yL53lvZ I fA�'� <br /> 2�w hAtIlwC /C70ty - <br /> TIME RECEIVED 3 ILO /y-1 TIME OF ARRIVAL) � TIME OF DEPARTURE 6 3 s—p- <br /> PERSONS AT SCENE AGENCY PH NE TOA TOD <br /> NAM <br /> IDENTIFICATION OF MATERIAL(citFwCALINVOLVED) ❑ GRANULE FORM ❑ SOLID ❑ POWDER ElQUIDGAS Q <br /> DATE MAILED <br /> REFERRALS TO <br /> UAR <br /> DATE COMPLETED........PROP 65 <br /> PERSONS EXPOSED and/or INJURED PH <br /> ONE <br /> NAME ADDRESS <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE.RF-COPD" COMPLETED? Cl YES El NO <br /> E. IND�R COP FS: <br /> NARR <br /> SHORT-TERM ON TOP ATIVE ❑ ANALYTICAL DATA Or EJ OTHER AGENCY REPORTS <br /> El EXPOSURE RECORD FEST ❑ CLEAN REPORT <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Hcalch Care Scrviccs <br /> 6/14/1999 <br /> EH22014rev.doc <br />