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PU C HEALTH ShAVICES D�ANIN. t <br /> SAN JOAQUIN COUNTY <br /> CONFI�L�' TIAL <br /> JOGI KHANNA M.D.,M.P.H. �'- `I <br /> Heahh Officer <br /> P.O. Box 2009 . (1601 Fast Hazelton Avenue) . Stockton,California 95201 �iFOAi <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# �3a ,�' DATE 16-30_ NT# <br /> PREMISE ADDRESS_ P4) t CF yYr py�� Sf. <br /> PREMISE OWNER__ S1c� F �1�riy�2a�J <br /> ADDRESS <br /> FACILITY CON'T'ACT <br /> NATURE OF COMPLAINT(explosion,spill leak fire,orabandon)dlanped material) <br /> A � <br /> -yam <br /> COMPLAINANT I�NI� ��� .AGENCY E, S. PE10NE NO. <br /> TIME RECEIVED__ J m ;_3 n TIME OF ARRIVAL 16; ys TIME OF DEPARTURF. Q <br /> PERSONS AT SCENE (TOA) (7UU) <br /> NAME AGENCY <br /> �adat3 Fal2ti.c�� 41 <br /> C_n O PHONE NO. TOA 'I'OD <br /> r-�,r,; pori <br /> C s,-accr�r� <br /> IDENTIFICATION OF MATERIAL.(citEMIGM.INvovED) W Q$�e �L(/� <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER I I GAS j e IOUID [ I ORANULH <br /> REFERRALS TO: <br /> I. ,• DATE. MAILED: <br /> DATE COMPLETED: PROP 65 Td"� eal UAR <br /> PERSONS EXPOSED and/or INJURE h <br /> NAME ADDRESS <br /> PI[ONE NO. <br /> INVESTIGATION REP RT INCLUDE FINDINGS CLEAN-UP.RECDMMENDATIONS..d MAP:O .SCE yyt <br /> J <br /> FILE CREATED [] MAP INCLUDED SHORT TERM ATTACHED ER <br /> [1 TEI?COPY[1 <br /> A Division of San Joaquin C.ounry Health Care Services <br />