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4 xy� <br /> y PUBLIC HEALTH SERVICES <br /> SAN JOAQIIIN COUNTY <br /> JOGI KHANNA M.D..M.P.H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) 0 Stockton, California 95201 <br /> (209)468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE SHORT TERM# CboOt«{� <br /> PREMISE ADDRESS AV LCly — CHy 5AA) '3c/Q veIlf Co <br /> s <br /> DBA �� G <br /> I <br /> PREMISE OWNER_l/ I¢� /!1�€© _- PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> NATU OF COMPLAINT(explosion, spill, leak, fire, or oned/dum <br /> TIME RECEIVED D fl TIME OF ARRIVAL 25-'=.J '°( _ TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> t <br /> a-,La. ��F <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> G <br /> SUBSTANCE FORM: [SOLID ( I POWDER [ ] GAS LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 !Z- / Zj __ uAR . Ai4 - - <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ( I YES NO <br /> I <br /> f E.R.BINDER COPIES: <br /> If SHORT-TERM ATTACHED ON TOP btNARRATIVE [ l ANALYTICAL DATA PROP 65/UAR <br /> [ ] EXPOSURE RECORD MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS MAP [ ] FILE CREATED <br /> A Division of San Joaquin County health tare Services <br />