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� ESPJBLICHEALTH SEKVICoPpU1N e <br /> SAN JOAQUIN COUNTY i `? <br /> JOGI KHANNA M D.M.P.H. S <br /> Health Officer <br /> r.. <br /> �P <br /> P.O. Box 2009 • (1601 Eau Hazelton Avenue) • Stockton, California 95201 q c(F 6 a <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# r DA(/TE �� "� , n / A //SHORT TERM # <br /> PREMISE ADDRESS/ / Z'7 7/D �. CSD ayw del CITY LeC.Y - <br /> DBA I� i. 6kQ-O fLot ��� Py(tM./ ✓"""�. � / <br /> PREMISE OWNER tt77 ,�,[[ PHONd_?I L'� 7v2, 6 1 of <br /> OWNER'S ADDRESS P 0I V V 1126 1A)x_e`��to_ 4aMd2.d'1 67;0 <br /> FACILITY CONTACT �Pd?2ei �(QISOCM e�Lti —PHONEXJB <br /> TU OF Ce4los s ill, 1 fire,pr a endo d ped roar <br /> am- <br /> TIME RECEIVED CP0 ,e44 TIME OF ARRIVAL 6 00 w TIME OF DEPARTURE 00 f'L <br /> (T A) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> 2Aau, Oc Ak_g%� �;on F6o of <br /> R � f <br /> -'�te 1wr I L7-0 v�^ <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID POWDER [ I GAS LIQUID ( ] GRANULE <br /> REFERRALS TO: DATE MALED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> N yF <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ I NO <br /> E.R-BINDER COPIES: <br /> [ SHORT-TERM ATTACHED ON TOP �] NARRATIVE ( ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ l REFERRALS MAP [ l FILE CREATED <br /> A Division of San Joaquin(ounry Hcalth :are xmca C� <br />