Laserfiche WebLink
PUBLIC HEALTH SERVICES ,oP �o <br /> SAN JOAQUIN COUNTY z <br /> ENVIRONMENTAL HEALTH DMSION y: ' <br /> Karen Furst, M.D., M.P.H., Health Officer . , P.. <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 c;FORa <br /> 209/468-3420 <br /> �—�1 EMERGENCY RESPONSE RECORD 2-7 <br /> DATE f�f U 00,� I. SHORT TERM# C0 Db 13 /2D <br /> r <br /> PREMISE ADDRESS �� � �. In00r- WOW OW CITY M6U14CO-0, <br /> DBA <br /> PREMISE OWNER �l�M� La� 1 � � JQ 5oeC4CU SPHONE rZO — 96?-?SSS <br /> OWNER'S ADDRESS 14 3 S r+ Va k CC- <br /> FACILITY CONTACT Da V CA Da S I �VPHONE W q- 0 p 5,6' .,2gSg <br /> RESPONSIBLE PARTY (RP) DBA SI�,IJ►-&-l/tGl S►O�Ci17 l,�S PP <br /> RP NAME JU,l._.II 'LiY ► I a S 6P A Q S PHONE '?n(2 <br /> RP ADDRESS . A-I Y 0 r'- VJ AA 0- U � <br /> RP CONTACT �aM. V�1 PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> SCUD Q a -11 p w r <br /> fi <br /> TIME RECEIVED TIME OF ARRIVAL •• AA TIME OF DEPARTURES:2-t'PO <br /> PERSONS AT SCENE �Q (1�� ' S �M �,• <br /> NAME AGENCY PHONE TOA TOD <br /> -� A 1: <br /> Loftba s Q %_ 1. <br /> -wmC <br /> ale ���►��es t- � s a _ _ <br /> IDENTIFICATION OF MATERIAL(CHEMICAL(NVOLV,D)�1/l}J <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: <br /> Z4 SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 65 / UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> EH22014rev.doc A Division of San Joaquin County Hcalrh Care Scrviccs 6/14/1999 <br />