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HEALTH SERVICES riPUBLICz. ��. ..� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION k�=.'' <br /> Karen Furst, M.D., M.P.H., Health Officer c4<<Foa �P <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 93202 <br /> 2091468-3420 <br /> EMERGEt`ICY RESPONSE RECORD <br /> 1 <br /> SHORT TERM # <br /> DATE rye <br /> CITY_ <br /> PREMISE ADDRESS <br /> � � f C <br /> DBA VYG5 { (•wY 11 PHONE ��9 <br /> PREMISE OWNER � � S � <br /> OWNER'S ADDRESS lrt Ve <br /> PHONE c{(o2. g7C77 <br /> FACILITY CONTACT " <br /> RESPONSIBLE PARTY(RP) DBA <br /> V PHONE <br /> RP NAME <br /> RP ADDRESS <br /> PHONE <br /> RP CONTACT <br /> i <br /> NATURE OF COMPLAINT(explosion, sill, leak, tire, or abandoned/dumped material) <br /> D - d r <br /> TIME RECEIVED f PNti TINIE OF ARRIVAL 2- 1 L40 P(✓1 TItiIE OF DEPARTURE Odder <br /> PERSONS AT SCENE AGENCY PHONE TOA TOD <br /> NAME u :3o P <br /> 1r j"j <br /> GVYIMCI L -P ty0 <br /> r GO r L�wy1 60 , '!5L-f 5 - 3. :-'DD P 51 <br /> IDENTIFICATION OF MATERIAL(cNswCALINVOLVED) Ir 2 :I'1 Pas <br /> GRANULE <br /> SUBSTANCE FORM ❑ SOLID ❑ PO DER ❑ GAS LIQUID G <br /> DATE MAILED <br /> REFERRALS TO <br /> UAR <br /> DATE COMPLETED........PROP 63 <br /> PERSONS EXPOSED and/or INJURED PHONE <br /> NAME ADDRESS <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES:M TIGAL DATA L1 PROP 5� 1 UAA <br /> SHORT-TERON TOP 2--NARRATIVE © ANp1 y <br /> C9 MANIFEST [3CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ EXPOSURE RECORD ❑ FILE CREATED <br /> © REFERRALS F.�:MAP <br /> A Division Of San Joaquin Count:- Health Care 5e:---ices <br /> r � <br />