Laserfiche WebLink
.r 1 pU�N <br /> HEALTH SERVICESPUBLIC .� <br /> SAN JOAQUIN COUNTY Q + <br /> N: :t <br /> JOGI KHANNA M.D..M.P.H. <br /> Health Officer c �p <br /> P.O. BOX 2009 0 ( <br /> 1601 East Hazelton Avenue) • Stockton, California 95201 4 c,F 640t <br /> (209)468-3400 / <br /> EMERGENCY RESPONSE RECORD G�cabl SQL{ <br /> DISTRICT# ��•-DATE 3 /� 9� SHORT TERM f# / <br /> PREMISE ADDRESS �� .lap s�ifl �� cm <br /> DBA �711 _�_ - <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT �Z— PHONE <br /> NATURE OF OMPLAINT (explosion, spill, �e or abandoned dumped material) <br /> A 5~r d<G <br /> TIME RECEIVED /v= 0 4D TIME OF ARRIVAL '610 TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TQD <br /> AT <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID L l POWDER [ ] GAS !` LIQUID [ ] GRANULE <br /> REFERRALS TO: �lY� DATE MAILED- <br /> /r A <br /> DATE COMPLETED: PROP 65 3�rg UAR All <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> N! <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E.R_BINDER COPIES: <br /> c�SHORT-TERM ATTACHED ON TOP [NARRATIVE [ ] ANALYTICAL DATA PROP 65/UAR <br /> [ ]\] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ]\OTHER AGENCY REPORTS <br /> E ] REFERRALS {'V MAP [ ] FILE CREATED <br /> A Division of san Joaquin(:ountv Health fare Sermes 01 <br />