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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 <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/465-3420 <br />DATE g /] g EMERGENCY RESPONSE RECORD <br />PREMISE ADDRESS F/ <br />DBA r <br />PREMISE OWNER )ry, <br />OWNER'S ADDRESS J Z LQL. O <br />FACILITY CONTACT ✓P r?I o -ea_ <br />FIL <br />OPY <br />SHORT TERM N <br />CITY <br />PHONE <br />PHONE <br />RESPONSIBLE PARTY (RP) DBA Ph *-E <br />RP NAME PHONE <br />RP ADDRESS AT 1 t jj, <br />RP CONTACT C�� t�PC%% PHONE <br />NATURE <br />spill, leak, fire, or <br />TIME RECEIVED _�— Z3 TIME OF ARRIVAL f" (/r <br />TIME OF DEPARTURE /I <br />PERSONS AT SCENE <br />NAME A�GEN�CY <br />n'.��er� �b <br />(TOA) <br />PHONE NO. <br />v (fOD)-� <br />TOA TOD <br />L 4 ur Gn 1 tjE <br />Uo- _ 7C": d <br />IDENTIFICATION OF MATERIAL (CHDUCALINVOLvm) <br />SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS <br />REFERRALS TO: DATE MAILED: <br />DATE COMPLETED: PROP 65 III / S UAR <br />PERSONS EXPOSED and/or INJURED <br />NAME ADDRESS <br />IQUID [ ] GRANULE <br />PHONE NO. <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" <br />E. R. ER COPIES: <br />[ SHORT-TERM ON TOP ["J"NARRATIVE <br />[]EXPOSURE RECORD C MANIFEST <br />,y [ ] REFERRALS M P <br />EH 22 014 4/96 <br />COMPLETED? [ ] <br />tj</NALYTICAL DATA <br />[]CLEAN UP REPORT <br />[ ] FILE CREATED <br />YES [ ] NO <br />(4—PROP 65/UAR <br />[]OTHER AGENCY REPORTS <br />A Division of San Joaquin County Health Care Services <br />