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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY °''a"I" <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 304 E.Weber Ave.. 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 8 .. <br /> 209/468-3420 <br /> E ofERGENCY RESPONSE RECORD <br /> DISTRICT DATE l'77 SHORT TERM /Z <br /> ?REMISE ADDRESS - t„ �^, CITY <br /> DBA <br /> ?REX SE-AVS /CptiifL� (��/ , PHONE <br /> OWNER'S ADDRESS <br /> FACII.ITY CONTACT PHONE <br /> NATURE OF COMPLAINT (e fosion, spill, leak, nre, or abandoned/dumped material) <br /> C i <br /> TIME RECEIVED _ S:2� 2CZ TIME OF ARRIVAL S: / ZiRM TIME OF DEPARTURE <br /> PERSONS AT SCENE (TOA) (TOO) <br /> NAME AGENCY PHONE NO. .. TOA TOD <br /> y <br /> - 3 rn <br /> /1, _54m- nol- 4y r 7. /o i a <br /> IDENTIFTCATION OF MATERIAL (CHEMICAL INVOLVED) A , — <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER ( ] GAS (y QUID [ I GRANULE <br /> REFERRALS 70: DATE MA=: <br /> DATE COMPLETED: PROP 65 -/ 7-2 6 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS <br /> Art. .r �I- Yit_l�A.h Z.2 ,� M!!-ir., R PHONE NO. <br /> �F G�irC.Cr_�tn. 937 �LS'S� <br /> rfir'�-i' . ,TA- X04, 7 /. &.a- se <br /> 'PERSONAL TOXIC SUBSTANCE E:40SURE RECORD" COMPLEMD? [ ] YES ( ] NO <br /> E. R. BINDER COPIES: <br /> [V6FORT-TER.1A ATTACHED ON TOP [ <ARRAiIVE [ ] ANALYTICAL DATA [ PROP 65/UAR <br /> ,, F- OSURE RECORD [V�( NIFEST [ ] CLEANUP FIRM REPORT ( I OTrEll.AGENCY REPORTS <br /> [ ] REFERRALS 1e. ( ] =- CREATED <br /> A Division of Sun.loayuin Countv Health Care services <br />