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G(I rV1j ,r y ar f tf <br /> PUBLIC HEALTH SERAICES `( ' "z� ��� <br /> PdV�N <br /> SAN JOAQUIN COUNTY 2: Z <br /> Q a <br /> JOGI KHANNA MR,M.P.H. �.. <br /> Health Officer <br /> P.O. Box 2009 (1601 East Hazelton Avenue) • Stockton, California 9501 'F d R <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DATE 22 �I DISTRICT# �20 SHORT TERM# /" �57/ <br /> PREMISE ADDRESS E I I 10++ Rd l(� rJr� C�.� CITY <br /> DBA CbUO�j La A <br /> PREMISE OWNER l n PHONE <br /> OWNER'S ADDRESS I nn <br /> FACILITY CONTACT '" f� PHONE <br /> 6YU- d,)Ux n v, u,+ vw <br /> NATURE 9F CO (explos' n, spill, leak, fire, or abandon d ma % <br /> � 5 f O �E'YraD <br /> P V1 1 ^_ <br /> QnAk " W- Oy/ <br /> qr <br /> TIME RECEIVED I Q Iki� TIME OF ARRIVAL `'1 -�S AzM P TIME OF DEPARTURE S I ,0 A-A <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAS 1 AGENCY PHONE NO. TOA TOD <br /> Lo c j 0D 11.uU A, <br /> �r o5h O K ES :0 <br /> 53 <br /> r1 - s <br /> „ ' ,, O <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) Inc �a5 <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [] GAS [ LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 � ZJ//y UAR <br /> � f <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES t/No <br /> E.R.BINDER COPIES: <br /> [ ] SHORT-TERM, ATTACHED ON TOP [NARRATIVE ANALYTICAL DATA [ ] PROP 65/UAR/CLEANUP MFR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [v]MAP [ ] FILE CREATED <br /> A Division of San Joaquin County Health Care Services '� <br />