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PUBLIC HEALTH SERVICES <br /> o�SAN fOAQLINCOUNTY <br /> JOG[MANNA M.D..M.P.K. s. I <br /> Healrn Officer <br /> P.O. Box 3009 . (1601 Easr Hazelcon Avenue) • Stockton, California 9522,01 gc'FopN <br /> (309) 468-3400 <br /> ENIERGENCY RESPONSE RECORD <br /> DATE - 9I DISTRICT # � �SHOO/RT,TERM# 9IIaS� <br /> PREMISE ADDRESS)556 S I/la-A-j Ed. CITY, S-/6 <br /> DBA RiC- LS 'truck <br /> . .h��lc <br /> PM%ffSE OWNER ti r ti-/"`� c,,/ PHONE <br /> C/D F Crh? <br /> OWNER'S ADDRESS Vv <br /> f� 0, 6ox in -Su,2, <br /> FACEI'IY CONTACT K i GK PHONE,`c2 91�f�3— F20 S' <br /> NATURE OF COMP Cexplosion, s 0,� Clre, or abandoned/dumped <br /> 1 <br /> TIME RECEIVED ,101 TIME OF ARRNAL Es'j 5 TIME OF DEPARTURE O r2An� <br /> (TOA) (TCDD <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. p TOA TOD <br /> F <br /> 1 <br /> IDENTIFICATION OFMA7 RIAL (CHEMICAL INVOLVED) }/1f � ✓//EC!/1� GCJCP57�S �At�JL7uOG? S o�fo �0 <br /> SUBSTANCE�OR'VI: , [ ] SOLID [ ] POWDER [] GAS [yID [ ] <br /> UGRA�WI.E <br /> REFERRALS TO: DD <br /> n DATE MAIN: I J!q//711LIQ <br /> DATE CObIPLET°..D: PROP 65 / 1/ UAR / <br /> PERSONS &'POSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> W 7T <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES [ ] NO <br /> E R.BINDER COPIES: � <br /> ( SHORT-TERIM ATTACHED ON TOP [l�]NARRATIVE [ANALYTICAL DATA [ ] PROP 6S/UAR/CLEANUP MFR <br /> [ ] EXPOSURE RECORD [ ] M/ANIFEST [] CLEANUP FIRM REPORT [] OTHER AGENCY REPORTS <br /> [ ] REFERR ALS [Y]/MAP [1�FELE CREATED <br /> A Division of San Joaquin Counry Heaith Care Services <br />