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PUBLIC HEALTH SERVICES � �fl <br /> SAN JOAQUIN COUNTY <br /> go <br /> ENVIRONMENTAL HEALTH DIVISION ` <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 � <br /> (209) 468-3420 <br /> EMERGENCY RESPONSE RECORD I <br /> DISTRICT# ?7Za DA'T'E �� 9 SHORT TERM# coda3z6$ <br /> ' 'r r .�f�T'� CIY <br /> t PREMISE ADDRESS O <br /> DBA �eAQ Sr-,Qc <br /> �. PREMISE OWNER S. L�vn!-r�Y E.4 5�iy,�.J?� PHONE <br /> OWNER'S ADDRESS <br /> FACILITY Y CONTACT 'PHONE <br /> NATURE OF COMPLAINT ( losion, spill, Tear,fire, or ahandoned/dum_ ped material} <br /> l <br /> 5 <br /> y <br /> TIME RECEIVED TIME OF ARRNAL 10!40 c?" TIME OF DEPARTURE <br /> (TOA) (TW) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> EBF <br /> i <br /> IDENTIFICATION OF MATERIAL (CHEMICAL IWOLVED) <br /> SUBSTANCE FORM: [ ] SOLID, [ ] POWDER [ ] GAS LIQUID [ 7 GRANULE <br /> >. Z <br /> REFERRALSTO: 11-tvA- DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS ! PHONE NO. <br /> i <br /> ° <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES NO <br /> E.R.BLNDER COPIES: <br /> SHORT-TERM ATTACHED,ON TOP 'NNARRATIVE [ ] ANALYTICAL.DATA rROP AR <br /> [ ] EXPOSURE RECORD [ ] ]MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> I <br /> C ] REFERRALS NAP [ 7 FILE CREATED <br /> i <br /> ' - I <br /> a ;1r•i.iun of San ,biaquin Counts Health Care Service, j <br /> k <br />