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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY =' s <br /> JOGI KHANNA M.D.M.P.H. w < <br /> Health Officer <br /> P.O. Box 2009 0 (1601 East Hazelton Avenue) *Stockton, California 95201 c P <br /> (209) 468-3400 <br /> MWERGENCY RESPONSE RECORD <br /> DISTRICT if �� DATE �O �/ SHORT TERM # <br /> PREMISE ADDRESS 17100)) 5- 44444d A.0 . CITY <br /> DBA 5449 G0• <br /> PREMISE OWNER 1pGA?VE4-7T �'/•�,G I PHO Z - '1!R00c <br /> 0y <br /> OWER'S ADDRESS 171SI IWlI I pw <br /> `zA—jh�eo fl C4 c�53-2z <br /> l FACILITY CONTACT SGa7 w ,&W j5�tl.4l\l PHONE(�Oq 9 FZ ' �18oy <br /> JATURE OF COMPLAINT (explosion, spill,leak, fire, or abandoned/dumped material) <br /> D �' AE SP/G L <br /> TIME RECEIVED ^ T-'00 a.7 TIME OF ARRIVAL - ct It., TIME OF DEPARTURE // 2J 0 Ct,..1 <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> sco i/ C Z� 98Z- <br /> i y7/- i <br /> 0 5 GG " - 7/Z <br /> IDENTIFICATION OF MATERIAL. (CHENICAL INVOLVED) <br /> SUBSTANCE FORM [ ] SOLID [ ] POWDER ( I GAS .[I�-t^i�UID [ ] GRANULE <br /> LS <br /> REFERRATO: Ag DATE MAILED: /^`�//•f— <br /> DATE COMPLETED: PROP 65 //� /C/ sJ UAR_�//T <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ANO <br /> E.R. BINDER COPIES: � <br /> SHORT-TERM ATTACHED ON TOP r NARRATIVE [ ] ANALYTICAL DATA ROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ]MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> C ] REFERRALS ['1P [ l FILE CREATED <br /> l <br /> A Division of W Ioagwn Coon HcaltN fare X ce C� <br />