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i , 7 <br /> U C <br /> PUBIC HEALTH SERVICLo ,o.°�U'� •.co <br /> SAN IOAQUII`COUNTY <br /> 4 :< <br /> JOGI KHANNA M.D,NI F H. <br /> Heah Officer P <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) ! Stockton, California 95201 i�o'R� <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> TP7c 4— <br /> DISTRICT # DATE-�� — SHORT TERM # <br /> PREMISE ADDRESS 4/ /T/ / � - CITY <br /> IrAA- <br /> DBA 1�..�T-✓fy �' f - <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS_/ <br /> FACILITY CONTACT —yam"'>�c �IPHONECG4""'t1 � <br /> NATURE OF COMP LATNi (explosion, spill,Teak, fire, or abandoned/dumped material) �- <br /> �6'/� <br /> TIME RECEIVED '�d TIME OF ARRIVAL �d' �ar� TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> 0 Z-- ' /w l/D <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) / S�GU�tCx� <br /> SUBSTANCE FORM: , 1 [ ] SOLID C ] POWDER [ ] GAS LIQUID C ] GRANULE <br /> REFERRALS TO:, /V/)�— 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? C ] YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ATTACHED ON TOP NARRATIVE C ] ANALYTICAL DATA [ PROP 65/UAR <br /> [ ] �.1 <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS y MAP [ ] FILE CREATED <br /> A Division of san Joaquin counry Health care Services <br />