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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer `P.. <br /> 304 East Weber Avenue,Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM# �,+ <br /> PREMISE ADDRESS 1.36 i �sd _ W a a CITY �7 '0 � K � <br /> DBA <br /> PREMISE OWNER AR t PHONE <br /> OWNER'S ADDRESS pp <br /> FACILITY CONTACT ")I- PHONE <br /> RESPONSIBLE PARTY (RP)DBA A (� <br /> RP NAME PHONE <br /> RP ADDRESS Cl S <br /> RP CONTACT [ D if h A PHONE Q <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped terial) <br /> , <br /> TIME RECEIVED , TIME OF ARRIVAL f TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICALINVOLVW) <br /> SUBSTANCE FORM ❑ SOLID . ❑ POWMR ❑ GAS 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 ❑ 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 />