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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY r` ` <br /> ENVIRONMENTAL HEALTH DMSION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 1 LSF O.Ra\ <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE a SHORT TERM# <br /> PREMISE ADDRESS C�y 1_� CITY <br /> DBA Cali S SI4:`1� � rt <br /> PREMISE OWNERF -^,''l" rt PHONE <br /> OWNER'S ADDRESS dvU Iy� v eS boa c"S C C, 23 q <br /> PHONE <br /> FACILITY CONTACT rn Irl](Se, <br /> RESPONSIBLE PARTY (RP) DBA (Tic,� <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT I--o b?L Z PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, tire, or abandoned/dumped material) pp / <br /> CL /LIZ d-e r S f� ..s✓�.S'-yrti it C_sz_ <br /> TIME RECEIVED R`'^ TIME OF ARRIVAL TIME OF DEPARTURE QJ-: 3 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> CSto �C �%c� X35 a <br /> IDENTIFICATION OF MATERIAL IcHE\HCAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS 1�rLIQUID ❑ 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 ❑ PROP 65 /UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS ❑ MAP ❑ FILE CREATED <br /> EH22014rev.doc A Division of San Joaquin County Health Care Services 6/14/1999 <br />