Laserfiche WebLink
. PUBLI(", HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI K.tIANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> Lf <br /> DATE a DISTRICT# SHORT TERM# !D5G 7 <br /> PREMISE ADDRESS D / CITY Tr <br /> CT <br /> DBA F-C n T L-9 <br /> PRE,MISE OWNER <br /> _. PHONE <br /> OWNER'S ADDRESS r rT CpIA QZZ4 <br /> f <br /> FACILITY CONTACT /1�a,u c-� PHONE( O S3. <br /> NATURE OF COLAINT (explosion, sp171, Teak, .Fire, or abandoned/dum mat ) <br /> Ael j2,2— AJ- <br /> G <br /> w <br /> TIME RECEIVED / Q TIME OF ARRNAL TME OF DEPARTURE .3 t YS,,)»� <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> t <br /> #09) <br /> IDENTIFICATION OF MATERIAL (CHEMICAL IWOLVED) Op t1. <br /> SUBSTANCE FORM: (/SOLID { ] POWDER [ ] GAS [ ] LIQUID C I GRANULE <br /> REFERRALS TO: A DATE MAILED: <br /> DATE COMPLE'T'ED: PROP 65 I UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> N ft- <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO i <br /> i <br /> E R BWER COPIES: <br /> I SHORT-TERIV ATTACHED ON TOP [ ] NARRATIVE CW;A 4ALYTICAL DATA [' PROP 65/UAR/CLEANUP MFR <br /> { I EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT C I OTHER AGENCY REPOR'T'S <br /> lid REFERRALS [ ] MAP C�FTLE CREATED <br /> A Division of San]oaquin County Health Care Services <br /> I <br /> t <br />