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PUBLIC HEALTH SERICES <br /> SAN JOAQUIN COUNTY =' <br /> JOCI KHANNA 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 /> DISTRICT# DATE 3 SHORT TERM # - <br /> ' s- <br /> PREMISE ADDRESS !yc2i`� '4— Z <br /> � '/i1 CITY�J D CIT <br /> DBA L �ir'drvn /�tO e-�/�C Aloe,e A,- (' <br /> PREMISE OWNER C`jCr//on PHONE (SIC) 6$C� <br /> OWNER'S ADDRESS 1,pV <br /> FACILITY CONTACT /✓I.//t ��+//t'�-� PHONE 6S i 6) 6 Fri -3I 6 y <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br /> i ew 'sn v 3s !✓M M <br /> TIME RECEIVED l/-'OO TIME OF ARRIVAL //! 30 aM TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> Vm14-e/C o'i zos- <br /> alPh nl,�m oc e -z m9 - 4�7H- yZ5/ /�) 30 <br /> tri S 3v <br /> 1W <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [41ULID ,/�[ l POWDER I ] GAS IUID I ] GRANULE <br /> � <br /> REFERRALS TO: (f j Cz L' TS DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ I NO <br /> E.R.BINDER COPIES: <br /> [ ] SHORT-TERM ATTACHED ON TOP [ ] NARRATIVE [ ] ANALYTICAL.DATA [ ] PROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ ] MAP [ ] FILE CREATED <br /> A Division of San Joaquin Counry Hcalth Care 5cmccs <br />