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7 J � <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />JOG] KHANNA M.D., M P H <br />Health Officer <br />P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, Califonua 95201 4i�FORr• <br />(209) 468-3400 <br />EMERGENCY RESPONSE RECORD <br />y <br />DISTRICT # w pDATE I-3 / SHORT <br />/ TERM # U <br />PREMISE ADDRESS 3 3 3/ /6 ' ✓' rt,d^r i` -"t + Cln 4 ce <br />DBA iw /IGS P� QO ,� -a" <br />PREMISE OWNER M .ntirn//A PHONE 365 <br />OWNER'S ADDRESS 2) <br />FACILITY CONTACT �j G- EYD r 1 PHONE GI —� <br />NATURE OF�OMJII�INT (explosion, {Pi6, leak, fire, or abandoned/dumrd material) _ �_ / <br />TIME RECEIVED / -23 0 P11 TIME OF ARRIVAL _ Z - CV PM TIME OF DEPARTURE 0 PM <br />(TDA) (TDD) <br />PERSONS AT SCENE <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) -574e T'(a <br />SUBSTANCE FORM: [ I SOLID [ POWDER [ I GAS &- L1QUID [ 7 GRANULE <br />REFERRALS TO: DATE MAILED: <br />DATE COMPLETED: PROP 6S �— UAR �— <br />PERSONS EXPOSED and/or INJURED PHONE NO. <br />NAME ADDRESS <br />'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? L 1 YES <br />E- R. ENDER COPIES: <br />�- <br />DATA <br />[ SSHHORT-TERM ATTACHED ON TOP <br />5/J NARRATIVE <br />(1%ANALYTICAL <br />`. <br />[ 7-MMANIFEST <br />(VJ CLEANUP FIRM REPORT <br />(9<;OSURE RECORD <br />[ ] REFERRALS <br />[, MAP <br />[ ) FILE CREATED <br />[] NO <br />[ ] PROP 65/UAR <br />[ ] OTHER AGENCY REPORTS <br />A Division of,an Joaquin Cnunry Hralh I sc scmces \�> <br />I <br />i <br />