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PUBLIC HEALTH SERVICES <br /> • SAN JOAQUIN COUNTY r. : <br /> w: a <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton,California 95201 4tr1°ot+� <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# //D11ATE J9 SHORT TERM# <br /> PREMISE ADDRESS I -1gA 5kau,) [�FY �- CITY <br /> `�S <br /> DBA C�.uvl C'rdj <br /> PREMISE OWNER Usc_ Yc- CU, U,�ISI(5n a 6 1C�.(' V l.lC CADAA AA IaJ PHONE 9`-I'r l ' <br /> OWNER'S ADDRESS 1 I`iqa '5Y w S�0� n, I 2-� <br /> FACILITYCONTACT JO�P IN�LLf(l PHONE 9{ A-aZ5 <br /> NA1(JRE OF COMPLAINT (�splll, leak, fire,or abandoned/dumped material) <br /> �1�,_0on_ e �OaalLpn-I-�f,v..L <br /> OCA <br /> TIME RECEIVED 00 TIME OF ARRIVAL �/.l Y✓l TIME OF DEPARTURE <br /> (TOA) &OD) <br /> PERSONS AT SCENE <br /> NAME - AGENCY - PHONE NO. TOA TOD <br /> f(c.(ck, Lpta. <br /> Iof M 1nki �/�, � al —wig[ 9 <br /> Z r1Q�A rfw, l)5 qt.{5{' ?ice i r <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) ?kC) n;) [9cC i'fA <br /> SUBSTANCE FORM: [] SOLID [ ] POWDER [ ] GAS GRANULE <br /> REFERRALS TO: KA _DATE MAILED: A <br /> DATE COMPLETED: PROP 65 5/��I R�" UAR x ft <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [Y] NO <br /> E.R.BINDER COPIES: <br /> ( I SHORT-TERM ATTACHED ON TOP [ ] NARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> •[ ] EXPOSURE RECORD [ ] MANIFEST [ 7 CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ l MAP [ ] FILE CREATED <br /> A Division of San Joaquin County Health CMe Semces 10 <br />