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PUBLIC HEALTH SERVICES41 <br /> oA�,�.lr+,.••o <br /> SAN JOAQUIN COUNTY � A <br />' JOG[KHANNA M.D- I.P.H. X <br /> Hezlrn Officer <br /> P.O. Box 2009 9 (1601 East Hazclton Avcnuc) •5tockcon, California 95201 04 L;-Fib-0 <br /> (209) 468.3400 <br /> E 41MGFNCY RESPONSE RECORD <br /> DISTRICTS DATE' S 9 SHORT TERM # o 0c)a 6,6 <br /> PREMISE ADDRESS OC) <br /> _<7 CrTy 7;;:::;.c y <br /> DSA a-}Cie, Q i (t bo W,-vi CCrt ei <br /> PREMISE OWNER PHONE Gos) k3 3 L 75,3e <br /> �, I <br /> OWNERS ADDRESS G Oa �✓• �c ���� �� /��.�y l4 S 3 7G <br /> FACILITY CONTACT_ i -r �l„St�✓�-C/ _ PHONE <br /> NATURE OF COMPLAINT-(explakon,sp"-leaf fire, or abandoned/dumped•material) ; <br /> TIME RECErVED 3 t7 TMIE OF ARRIVAL_�` J� TIME OF DEPARTURE <br /> (70A) (TCD) <br /> PERSONS AT SCENE <br /> N ME <br /> AGENCY PHONE NO. TOA TOD <br /> //d • O 3 3� .. <br /> C AA / P S/14101- <br /> IDENTIFICATION <br /> 6rIDENTIFICATION OF MATERIAL. (CHEMICAL INVOLVED) t0w&Se I` -r- <br /> SUBSTANCE <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS ULD [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 6S UAR <br /> PERSONS EXPOSED and/or INSURED <br /> NA+ ADDRESS PHONE NO. <br /> s <br />�. <br /> 'PERSONAL'TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? L l YES L ] NO <br /> y <br /> E.R.L3 ER COPIES: <br /> ti <br /> f <br /> CER <br /> M ATTACHED ON TOP. NARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> ( I EXPOSURE RECORD [] [ ] 0 ANNUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REIFERRALS [ ( ] FILE CREATED <br /> t <br /> A Division of San Joaquin County Hcllth c4m Scrv,ca 10' <br />