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HEALTH SERVICESPUBLIC ..G <br /> SAN JOAQUIN COUNTY :? <br /> ENVIRONMENTAL HEALTH DIVISION H: ` <br /> Karen Furst, M.D., M.P.H., Health Officer • c; P.. <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 /Fo'RN <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE ' I SHORT TERM# <br /> PREMISE ADDRESSp�,r CITY �L C.�`�O' A <br /> DBA r19L(O c S S <br /> PREMISE OWNER G 1e ld r / l k S PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DBA c) <br /> RP NAME �l,tF �Sa We S 40uti�u Sous ccs (li ¢ PHONE <br /> RP ADDRESS 2�� Cl614CIS CIA A- <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> ,a <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> yts <br /> IDENTIFICATION OF MATERIAL(CHEMICAL rrvowED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS 4,IQUID ❑ 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 /> ❑ SHORT-TERM ON TOP ❑ NARRATIVE ❑ ANALYTICAL DATA El PROP 65/UAR <br /> 11 EXPOSURE RECORD El MANIFEST El CLEAN UP REPORT El OTHER AGENCY REPORTS <br /> ❑ REFERRALS ❑ MAP ❑ FILE CREATED <br /> EH22014rev.doc A Division of San Joaquin Counry Health Care Services 6/14/1999 <br />