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PUBLIC HEALTH SERVICES 'OTgUIry <br /> 11 4 0J 0 SAN JOAQUIN COUNTY <br /> ,5-10 4-24 5-174 Cv/L OGI nHANNA M.D.N.P.H. <br /> Health Officer <br /> �P <br /> P.O. Box 2009 • (1601 East Hazelton Av nue) • Stockton, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT # �DATE l0 9 SHORT TERM # <br /> PREMISE ADDRESS -Ta[JG-3c^ -q?-,A CITY <br /> DBA �C?�i \�0.. � �� ?)Cs1!'?.1-S / <br /> PREMISE OWNER PHONE -57-J/0 �i�Z <br /> OWNER'S ADDRESS I Z �� • ',,4 je R�nr l S-{- L1 )-v -�qcf«c <br /> FACILITY CONTACT�.R [.ICJV�"l PHONE TU(% S~/C C3-z) X <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) IS` <br /> TIME RECEIVED .7' I Qih.. TIME OF ARRIVAL ' 114#1-) TIME OF DEPARTURE� �� Z) ! �Yn <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> IDENTIFICATION OF MATERW. (CHEMICAL INVOLVED) D`�y'I F..r La <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS Pq_.LIQUID ( ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 W If` '9(� UAR <br /> PERSONS EXPOSED and/or INJURED <br /> '.NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ I NO <br /> E. R- BINDER COPIES: <br /> taSHORT-TERM ATTACHED ON TOP (X NARRATIVE [ I ANALYTICAL DATA 'bd.PROP 6S/UAR <br /> [ I EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [d MAP [ ] FILE CREATED <br /> \Dlatislnn nt Vn 1�wWm(ounry Mc�lUt t'ue xmces C 1 <br />