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PLBL,11" HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D.M.P H <br />Healch Officer <br />P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br />(209) 468-3400 <br />EMERGENCY RESPONSE RECORD <br />DATE / •-f' DISTRICT # a SHORT TERM # <br />PREMISE ADDRESS ;77? 5 6/ 44.-f_ .4,-1,1 .7._ 4 1.) <br />DBA e <br />PREMISE OWNER PHONE <br /> <br />OWNER'S ADDRESS 4 ?:4' 7 <br />FACILITY CONTACT Sa.111,C__ („L.,i LC- PHONE <br />NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandonediimped material) trj a Q IC 1 <br />- • <br />TIME RECEIVED / O.' C) TIME OF ARRIVAL / / : C) TIME OF DEPARTURE <br /> <br />(TOA) (TOO) <br />PERSONS AT SCENE <br />NAME AGENCY <br />AR1/N:77- <br />, . „c2 (,eio-r, /_S) c.P <br />12 ; r.fec' -ci ; c-c,s j)c, t- <br /> <br />PHONE NO. TOA TOD <br /> <br />IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) (141::)( A '7/tit 4 j hi "In) 41 il_) /546( e• -ef!..1-6--y,o(),(7 -' 7 <br />SUBSTANCE FORM: [ ] SOLID [ 1 POWDER [ ] GAS (WI:IQUID [ ] GRANULE <br />REFERRALS TO: DATE MAILED: <br />DATE COMPLETED: PROP 65 / 0 —A 3 - 9,.-, UAR A/ f-lt <br />PERSONS EXPOSED and/or INJURED <br />NAME ADDRESS PHONE NO. <br />'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ 1 YES [1 NO <br />E. R. BENDER COPIES: <br />$SHORT-TERM ATTACHED ON TOP NARRATNE [ ANALYTICAL DATA PROP 65 AR <br />[ ] EXPOSURE RECORD (]MANIFEST []CLEANUP FIRM REPORT [ 1 OTHER AGENCY REPORTS <br />?<REFERRALS ;i{MAP ‹FILE CREATED <br />A Division of San Joaquin Counry Health Care sery,ccs