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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> r„ .2 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' Karen Furst, M.D., M.P.H., Health Officer P <br /> ! 304 East Weber Avenue, Third Floor. a Stockton, CA 95202 <br /> 209/468-3420 ` <br /> : EMERGENCY RESPONSE RECORD <br /> I DATE "'. .9 I SHORT.TERM# COOoq �$"L <br /> PREMISE ADDRESS- Z� c�G+ S v4 C-or - CITY <br /> .- 'DBA .Gv�'oG. r <br /> PHONE <br /> PREMISE OWNER <br /> . OWNER'S ADDRESS 16 av <br /> FACILITY CONTACT G4 447--- /-U . .PHONE_ <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> - -RP CONTACT PHONE <br /> .NATURE OF COMPLAINT(explosion, s M Eak, fire, or abandoned/dumped material) <br /> i <br /> TIME RECEIVEDTIME OF ARRIVAL'nV// tz0''ti TIKEOFDEPARTURE�..i'� �pl�` <br /> I PERSONS AT SCENE.: <br /> NAME / AGENCY PHONE <br /> I : <br /> 1 <br /> I <br /> IDENTIFICATION OF MATERIAL ttxtanenLmvowmt •�/'� �' <br /> i -SUBSTANCE FORM: [] SOLID ... [I POWDER. . [] GAS IQUID .[) GRANULE <br /> - <br /> REFERRALS TO: DATE MAIF ED: .- <br /> DATE COMPLETED: PROP 65�5,114 f'1y - UAR <br /> PERSONS EXPOSED'and/orINJURED - - <br /> ADDRESS PHONE NO. <br /> PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? f YES - [1 NO <br /> E. R..BINDER COPIES: - - <br /> [I SHORT-TERM ON TOP . - (1 NARRATIVE ' []ANALYTICAL,DATA `[]PROP 65/UAR <br /> [)EXPOSURE RECORD_ [) MANIFEST ' . [1 CLEAN UP REPORT `.�[I OTHER AGENCY REPORTS <br /> [1 REFERRALS : '[ I MAP ..: : .{,1.FILE CREATED " <br /> BE 22 014 4/96 <br /> ADivision of San Joaquin County Health Care Services <br />