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PUBLIC HEALTH SERVICES ar�u , <br /> 0� <br /> SANJOAQUINCOUN'IY r. Z <br /> P: <br /> . JOGI]G'iANNA SLD.,N.P.H. �. <br /> Health Officer <br /> P.O. Box 2009 (1601 East Hazelton Avenue) • Stockton, California 95201 "aR <br /> (209) 468-3400 <br /> J EMERGENCY RESPONSE RECORD <br /> DATEY _�j DISTRICT# SHORT TERAS# <br /> PREMISE ADDRESS 1/'7 4 7 �{• f�,�-6rti 9.J4-j �QJ ,u� Cin <br /> DBA <br /> PREMISE OWNER qPPHONE Ca/'�� 76 DL-- 7A ?O <br /> OWNER'S ADDRESS I J (( / / e d, D O -ba-0o ,,J TX 752SzC <br /> p <br /> FACILITY CONTACT 0 Fln/t, S I\cl L(may ye I PHONE Ca04� Cl�3- 51"0 S <br /> NATURE OF CONIPLA1NT (explosion, spell, 1 fire, or abandoned/dum material) <br /> 9014 <br /> TIME RECEIVED { ] TLME OF ARRIVAL- ��� O C) TIME OF DEPARTURE <br /> (TOA) (TCO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> r✓._, , d n Y 1 4' 3- S _ S- <br /> /3n *: L, ,Lz, 1 d 1 .it ry aft / i 1 ` r i i i /r <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORIM: Q[ ] SOLID [ ] POWDER [ I GAS p�[(�}/'11,IQUID [ ] GRANULE <br /> REFERRALS TO: �ub,6 Qi v�-G`�(h'�Aij y✓���1. DATE MAILFD: . /V 14 <br /> DATE COMPLETED: PROP 65 7 -�- �Z/ UAR <br /> PERSONS EXPOSED and/or INJURED <br /> 7� NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES [ ] NO <br /> E R BINDER COPIES: J/ <br /> SHORT-TERM ATTACHED ON TOP [/NARRATIVE [ ] ANALYTICAL DATAROP 65 AR/CLEAaWP MFR <br /> C ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ ] MAP J ILE CREATED <br /> A Division of San Joaquin County Healrh Care Services <br />