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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> Q: <br /> JOGI I:HANNA 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 /> DATE /Z (17q, DISTRICT# 3.7,4-( SHORT TERM# <br /> PREMISE ADDRESS 001 <br /> ��m h.r•: {C.1 P tic CITY eX <br /> r <br /> DBA McN r,r /In F`l�'n)•ry.4crt, lr.• f�rr�'�:l ��r ,/r�,�'�_ l(/4% <br /> PREMISE OWNER ,z '�i -�v �c l�oc�1 ��iSfllcPHONE `.33C X34"5" <br /> OWNER'S ADDRESS -1 fb.,v T?SS-3O3 3 <br /> ✓�. ,G Fltl..,, <br /> FACILITY CONTACT lJ.!h l: Ye ,•1'M N pl-f•ve <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or/abandoned/dur material) <br /> WN car• h•re+�rve!.7 �-l�w� U�'� ?� xlrcaf5 r't, E"� <br /> �/ it w,c�tn ru l /pu�tpa( (! �<t •�. r��1 �rrt(S �tr/� Md•rfC1lc l.�� Cr SlrS„ ri <br /> TIMERECEIVED X`I TIME OF ARRIVAL r� Dn^ TIME OF DEPARTURE l/' 3e .4" <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> D<+.,.v is F,,,fcf-S s v.(- OE'S :c Or7,'/6t 3'rEq q:s'd,g.... ti%c!:y r 4,4 <br /> ri- S '.C. O l'S T:S'0 l[7 ti/S .Q.M <br /> r/iu�cfz I1/ /(tri �• <• n+' t :'rd .,J ^�3ct>'c� G-fin i ✓ /P:ys- <br /> { . ,. G i ^>r ? cc.• �� Geo ; S� ^' /Z� : Y!5- <br /> IDENTIFICATION <br /> SIDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [t,�SOLID [ ] POWDER [ ] GAS [ ] LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAP. <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> NCS 1Nlz, <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES [J� NO <br /> E.R.BINDER COPIES: <br /> (SHORT-TERM ATTACHED ON TOP [Y- NARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR/CLEANUP MFR <br /> ,,,lift ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> REFERRALS MAP [ ] FILE CREATED <br /> A Division of San Joaquin County Healon Care Services <br />