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FILE COPY <br /> PUBLIC HEALTH SERVICES �o <br /> SA_- JOAQUIN COUNTY 2` <br /> NVIRON-NIENTAL HEALTH DIVISION <br /> Ernest N1. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 445 N. Sa Joaquin Street • P.O. Box 388 a Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE d - SHORT TERM# <br /> PREMISE ADDRESS 1 d-O CITY LOGO <br /> DBA Sa-7/ 1D ryt b --E4 <br /> f <br /> PREMISE OWNER AU rn PHONE <br /> OWNER'S ADDRESS I Z O l r eC vY1 �Dc�.t <br /> FACILITY CONTACT {'I .1 cal PHONE 33 Ll` S 000 <br /> NATURE OF COMPLAINT(,eiq:)1adon, spill, ore, or abandoned/dumped material) <br /> TIME RECEIVED -Z TIM'OF ARRIVAL 4'319 TIME OF DEPARTURE `�S <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> N AGENCY PHONE NO. TOA TOD <br /> S' Fx 3= D <br /> d� V- r o <br /> A /6 9— J1 Zo ti`%vd <br /> IDENTIFICATION OF MATERIAL (CHEMICAL 1XVOLVED) A 1�1177 <br /> SUBSTANCE FORM: [ ] .LID [] POWDER [ ] GAS LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E.R-BINDER COPIES: �/ <br /> SHORT-TERM ATTACHED O TOP X `IARRATIVE [ ] ANALYTICAL DATA PROP 65/UAR <br /> [EXPOSURE RECORD /[] MANIFEST CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ ] FILE CREATED <br /> of San Joaquin County Health Care Services <br />