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PUBLIC HEALTH SERVICES ,oto o` <br /> SAN JOAQUIN COUNTY < ; <br /> JOG[ KHAN-NA M.D..S1.P_H. l <br /> Health Office: <br /> P.O. Box 2009 (1601 Ease Hazelton Avenue) • Stockton, California 95201 c F 60t <br /> (209) 468-3400 <br /> DISTRICT 1 DATE EbffitGENCY RESPONSE RECORD <br /> SHORT TERM # 000 �03 <br /> PREMISEADDRESSflqS ,�,y ,./ <br /> DBA —{—,�'�C�/' L%+L�':NI� �'� !'V<C C fl'CP <br /> 1. t &S '�`�_ <br /> PREMISE OWNER / PHONE t <br /> OWNER'S ADDRESS <br /> FACrLTTYCONTACT 1�/�� PHONEy � �� 46S <br /> NATURE OF CQWLAINT0n, sp ,leak, fire, or abandoned/dumped tP^al p _ <br /> , a-Ooo a, <br /> TIME RECEIVED -[)Udpi 71ME OF ARRIVAL �' cvU '" TIME OF DEPARTURE �Z: UU <br /> (TOA (Tc6) <br /> PERSONS AT SCENE <br /> NAME AG CY PHONE NO TOA TOD <br /> /4g� <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) 0 <br /> SUBSTANCE FORM: [r]-SOLID SA'15 [] POWDER [ ] GAS fi]'LIQUID F•T [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 '�Djgs UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> i <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COWI.E=? [ ] YES [ I NO <br /> E.R.BINDER COPIES: <br /> [� SHORT-TERM ATTACHED ON TOP [-3-NARRATIVE &-?'ANALYTICAL DATA '{'f tPO 65 AR <br /> [ ] EXPOSURE RECORD [`MANIFEST [CLEANUP FIRM REPORT [ ] AGENCY REPORTS <br /> [ ] RE-°ERRAL.S E4 MAP [ ] FILE CREATED <br /> A Dmof San 102gwn Cowin Nam C„'x M 40 <br />