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i <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION �` :j <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer .. P <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT#--f--DATE �' 9 SHORT TERM #Cbao/607 <br /> PREMISE ADDRESS Co,+?,eAL /�vGGUw �'fJ. '/oo�w65T of .SS•d ayJ~CITY TAY <br /> DBA �1'a4�1Sif�� <br /> PREMISE OWNER .s44 g2DAou,,� Cy u&f'T X PHONE <br /> OWNER'S ADDRESS SAKI�yr9G�ui!f �ovnrTY <br /> FACILITY CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, spill, I__1' <br /> fire, or abandoned/dumped material) <br /> TIME RECEIVED �' /a G'^7 TIME OF ARRIVAL TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> _VF ya�sGo c9, s. 9 <br /> ,fc . c• S,3 —8920 <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) 11Cy6L <br /> SUBSTANCE FORM: [ ] SOLID [ ) POWDER [ ] GAS LIQUID [ ] GRANULE <br /> REFERRALS TO: 4A / DATE MAILED: AII/�" <br /> DATE COMPLETED: PROP 65 3/Z�/C/N UAR 1414- <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: 1 <br /> SHORT-TERM ATTACHED ON TOP XNARRATIVE [ ] ANALYTICAL DATA PROP 65/UAR <br /> [] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ MAP [ ] FILE CREATED <br /> A Dkision of San joaquin CUuntN Health Care Services <br />