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PUBLIC HEALTH SERVICES <br />SAN IOAQUIN COUNTY r <br />JOGI KH ANNA M.D . M.P.H. <br />y '.< <br />Health Office, " <br />P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 e4`i F o Rai' <br />(209) 468.3400 <br />EMERGENCY RESPONSE RECORD <br />DISTRICT # __ DATE % Z! SHORT TERM # <br />PREMISE ADDRESSyJ�G��DD o�-+L`7' Q�L�{/f CI1Y �LY <br />DBA � 1 5;7 C��Di l? M� <br />PREMISE OWNER �G>L r SV Ga.ePo Tsd� PHONE (Gcf►) 8 3ZJ O <br />OWNER'S ADDRESS <br />FACILITY CONTACT ��G��/- ,���G�� PHONE��)g2JS <br />NATURE OF COMPLAINT (explosion, sp 4 leak, fire, or abandoned/dumped material) <br />ynl ,e4 G'vEL en X/ <br />TIME RECEIVED '? - �? D C4e:�._ TIME OF ARRIVAL ) / - 7S_gel TIME OF DEPARTURE 12"/_5 <br />a� <br />(TOA) (TOD) <br />PERSONS AT SCENE <br />NAME AGENCY PHONE NO. TOA TOD <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED)b )C�ei5Z- 0 �l_ <br />SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS ` (LIQUID [ ] GRANULE <br />ILED <br />REFERRALS TO: [� I A- DATE MA: <br />DATE COMPLETED: PROP 65 zzZ ') LIAR <br />PERSONS EXPOSED and/or INJURED <br />NAME ADDRESS PHONE NO. <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [I NO <br />E. R. BINDER COPIES: <br />[ ] SHORT-TERM ATTACHED ON TOP [ ] NARRATIVE [ ] ANALYTICAL DATA VROP 65/UAR <br />[ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br />[ ] REFERRALS [ ] MAP [ ] FILE CREATED <br />A Dwmon of ,an Joaouin Counry Health Care 5cry ccs C�� <br />