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PUBLIC HEALTH SERVICES ��p.4U!N <br /> SAN JOAQUIN COUNTY r. x <br /> JOGI KHANNA M.D,MT H <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 c'°tlko'nP v <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE <br /> ,l �pnn �7 SHORT TERM# <br /> PREMISE ADDRESS we44z4/X CITY Z-4-17/JJ0/� <br /> DBA 15• F' Co <br /> PREMISE OWNER -ta,e PHO Zt-1-906 <br /> D9O <br /> �V <br /> OWNER'S ADDRESS 7(00 130)`✓Z7fZ " <br /> 44A-rh6POI0 C4 �K3jD <br /> FACILITY CONTACT 4 i' AAJ PHONE(7-oa <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br /> lPs"014 /-- <br /> TIME RECEIVED " `I DD -k TIME OF ARRIVAL 9P K-t TIME OF DEPARTURE <br /> (TDA) (TDD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> 5co i/ Z� 98Z- <br /> sT v. — 417/— <br /> TO-1 -- /Z <br /> -911A7 o iTt� - <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS .[I.�tI�UID [ ] GRANULE <br /> REFERRALS TO: A4 • DATE MAILED: <br /> DATE COMPLETED: PROP 65 �J//� / 7 UAR��� <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ I YES [a—NO <br /> E.IL BINDER COPIES: <br /> r HORT-TERM ATTACHED ON TOP [•, NARRATIVE [ ] ANALYTICAL DATAROP 65/UAR <br /> [ I EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [q MAP [ ] FILE CREATED <br /> A Division or San Joaquin Counry Health CarcSemces <br />