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PUBLIC H?ALTH S <br /> SAN JOAQUIN COUNTY <br /> Q: Zi <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 /> 209/468-3420 <br /> /� ,"� EMERGENCY RESPONSE RECORD <br /> DATE . I 11(iYU.I(t SHORT TERM# <br /> P.REMISE`,,A/DD�RESS CITY <br /> U� + <br /> DBA <br /> 1 l mact PREMISE OWNERJR Iv n TA i( PHONE 1a2 ' 0 o <br /> ��� <br /> OWNER'S ADDRESS l°I a"W? ✓� 616&Xb <br /> FACILITY CONTACTUA w l i PHONE (02 g�7 <br /> RESPONSIBLE PARTY(RP) DBA 5tDi�pl wo Lta'n <br /> RP NAME 4-1alwIt a4 (i1100 ye- PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, tire,or abandoned/dumped material) Vll�' <br /> D - Pd r (.WRQ <br /> TIME RECEIVED 2' AA TIME OF ARRIVAL 40 PM TIME OF DEPARTURE Cj . DOPM <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 1 :30 P 9..:40P <br /> '`pGv>�l MGI ram i -PyYowy�"('a. 2-9-7D-7 <br /> Cor <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWTDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED........PROP 65 1191/'7r-101 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 /> �� <br /> ER'SHORT-TERM ON TOP l7 NARRATIVE ❑ ANALYTICAL DATA L`7 PROP 65 /UAR <br /> ❑ EXPOSURE RECORD O MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS 2-MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />