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PUBLI(!MIUALTH Sr ES <br /> V <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.-M.P.H. <br /> - - moi <br /> Hvlth Offic,r ' <br /> P.O. Box 3009 • (1601 East Hazelron Avenue) . Scockron, California 9501 C!F O R <br /> (309) 468-3400 <br /> ]NIERGENCY RESPONSE RECORD <br /> J SHORT TERM# <br /> DATE I �ie ;FLDISTRMCT# i <br /> PRE'NtISE ADDRESS CITY ' 7J~tirt�' <br /> DBAi'C'GC ^ <br /> PRE:4IISE OWNER PHONE <br /> OWNER'S ADDRESS - � �/G G�L L !/�"7 ' � 21-a <br /> FACII.iTY CONTACT_ �'`G� = vaof ► PHONE 3G /t� <br /> NATU'R'E OF COMPLadNI' (eeplosio<spaL lealt, fire, or abandoned/dumped=renal) <br /> •rte/�/J� �'� ^ �t� — /�t1 �-�.G.�ta/� CSF .�.��L_��-'�G_ `l��tta ��-�,m'TbF- <br /> M12 RECEIVED TME OF ARRIVAL "I TL'viE OF DEPARTURE <br /> (TOA) (TCD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> 267 — <br /> il'F-� (i'1 cC�-T�� S. � Chi. >'�C�•T� F!�...� Li�T --- --- — <br /> IDENTIFICATION OF MAT-ERIAL (CHEMICAL INVOLVED) 1 % Z7 . <br /> SUBSTANCE FMM: [ ] SOLID [ ] POWDER [ I GAS X'LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE.MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PEMONS EXPOSED and/or INJURED <br /> NAtiIE ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXP�OySURE RECORD' COMPLETED? [ ] YES NO <br /> E.R.BINDER COPIES: /�P� <br /> V, SHORT-TER-M ATTACHED ON TOP [] NARRATIV`E [ ] ANALYTICAL DATA PROP 6SXLZANUPWR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT El OT 1E AGENCY REPORTS <br /> [fJ<V-V [ ] T�. CRE,�i:D <br /> A Division of San Joaquin Cuuncy Hcalch Car:Services �• <br />