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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY r` z <br /> ENVIRONMENTAL HEALTH DMSION * <br /> Karen Furst, M.D., M.P.H., Health Officer /I// / <br /> 304 East Weber Avenue, Third Floor• Stockton, CA 95202 51 4L,_ <br /> MS 1`'� 6L <br /> 209/468-3420 O'cz fj Z — 3?(G <br /> -7 EMERGENCY RESPONSE RECORD <br /> / <br /> DATE , D Z SHORT TERM# Gy 6 O -7 3 <br /> PREMISE ADDRESS I S I Do -r6^#\j6N eD CITY L DD; <br /> DBA TtA VQ i LA 2 'OV <br /> PREMISE OWNER S Ate- PHONE <br /> OWNER'S ADDRESS f p-01 $0\,4 1'-I 'S Oil 0 b(v g h UT 'N(415 '— 0310 <br /> FACILITY CONTACT r PHONE It 33y' y7`SLj <br /> RESPONSIBLE PARTY (RP)DBA rzrz F I In �f Q vLI P l 2 4 <br /> RP NAME M Rr c- IJDr I �c-v� PHONE(26-7 319 <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> 124 A,(-K fn 42 <br /> TIME RECEIVED ' t,3 D A M TIME OF ARRIVAL '�D A 1y TIME OF DEPARTURE `� yj DM <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> �rV_I' SSG beI�g F,re- DeP 331-751 0S3o <br /> Com �S C �� � y6$-3�1l Bso 417�Co <br /> w�� <br /> S w� A►-� S <br /> L or, o tp 1 g7,ol r G - D. 1- . ly�► v l(a o <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) me-c,,01 YUd, ( <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS NrLIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 UL 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 /> N 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 /> A Division of San Joaquin County Healrh Care Services 6/14/1999 <br /> EH22014rev.doc <br />