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s <br /> ' PUBLIC WEALTH SERACESFIL <br /> SAN JOAQUIN COUNTY <br /> �G <br /> ENVIRONMENTAL HEALTH DIVISION <br /> M. D. M.P.H. ActinHealth Officer r <br /> Ernest M. Fujimoto, , g .. <br /> 304 E. Weber Ave., Third Floor • P. O. Sox 388 • Stockton, CA 95201-038$ oatlFo�� <br /> 209/468-3420 <br /> DATE ZZ <br /> EMERGENCY RESPONSE RECORD (?? 70 <br /> SHORT TERM# <br /> PREMISE ADDRESS !:(/ CITY <br /> DBA i VeAtl <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT GL( PHONE <br /> RESPONSIBLE PARTY (RP) DBA vi' AU <br /> RP NAME PHONE — Q <br /> RP ADDRESS "y <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, spill, k, fire, or abandoned/dumped mate) <br /> S <br /> TIME RECEIVED J , 5O TIME OF ARRIVAL '`f . I S _ TIME OF DEPARTURE <br /> PERSONS AT SCENE (EOA) (IOD) <br /> NAME AGENCY PHONE NO. TOA TOD <br /> KV <br /> Q ted`- `G'�� N <br /> 15 r i S XD/15 H v <br /> ryN. 1 <br /> IDENTIFICATION OF MATERIAL (CHENICAI-IxvOLVED) <br /> SUBSTANCE FORM: [I SOLID [ ] POWDER [I G S LIQUID (] GRANULE <br /> REFERRALS TO: y DATE MAILED: <br /> DATE COMPLETED: PROP 65 / y UAR `I /-7 <br /> ^ !z 7 Z �? 7—,�Z %�6— <br /> PERSONS EXPOSED and/or INIURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ I NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP �ARRATiVE j I ANALYTICAL DATA PROP 65/UAR <br /> [ I EXPOSURE. RECORD `[ I MANIFEST [ I CLEAN UP REPORT [ ] OTHER AGENCY REPORTS <br /> [ I REFERRALS RMAP [I FILE CREATED <br /> EH 22 014 4/96 <br /> A Division of San Joaquin C,)untti-Fie:ith Care Ser-'ices <br />