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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION Q �^ <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 °4t;aoRN`r <br /> 209/468-3420 / <br /> EMERGENCY RESPONSE RECORD SHORT TERM COOX <br /> DATE "� �� �1 <br /> PREMISE ADDRESS ' - ^` ` ITY S / ,1 <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY (RP) DBA /P " n_yl <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT, PHONE <br /> NATURE OF COMPLA� (explosion. spill, leak, fire, or bandonedldumped mawnal) <br /> S P <br /> 1 �. -d2 <br /> TIME RECEIVED -5 %X ,6r1. TIME OF ARRIVAL /O%V D/ TIME OF DEPARTURE /O =<30 hiq . <br /> CrOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> DENTIFICATION OF MATERIAL (cxnuic iwmveot /�o✓ �r— <br /> SUBSTANCE FORM: ( ] SOLID [ I POWDER ( I GAS ( LIQUID ( I GRANULE <br /> REFERRALS T0: DATE MAILED: �— <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INSURED <br /> NAME ADDRESS PHONE NO. <br /> .PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED' [ I YES [ 1 NO <br /> E. R. BINDER COPIES: <br /> [ SHORT-TERM ON TOP [ NARRATIVE ( 1 ANALYTICAL DATA ( ] PROP 65/UAR <br /> ( ] EXPOSURE RECORD [` ]�MANIFEST [j CI.E.AN UP REPORT ( ] OTHER AGENCY REPORTS <br /> ( ] REFERRALS lh ` [ ] FIT-- CREATED <br /> EH 22 014 4/96 <br /> A Cic,Sion or fan Ioaa::in Coun, �-ieaith Care�vr xes <br />