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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY =` s <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> C `p <br /> P.O. Box 2009• (1601 Eur Hazdton Avenue) • Stockton, Califibmia 95201 <br /> (209)4683400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE SHORT # <br /> PREMISE ADDRESS d3 oT-O ��//66'7'a./.eo 4'LL/ hf.�/GF' C11Y S ��110;n^DBA �i Gtt_.rJ' YTi�?1f^" d Gl r4 SY7�S . <br /> PREMISE OWNER t7'r S-joPHONE 95/y-8 �a3 <br /> 7 <br /> OWNER'S ADDRESSSO-t7 Al k� Dom• /z�cfC-./,Oft f CA <br /> FACILPIY CONTACT Pn i i++ O r eC �te c-cY PHONE 9,wY-F 7/2 <br /> NATURE OFF C LAAJINT (explosio sp 1 fire, or abandoned/dumped lmaterial) I <br /> / S!Y �i•Wf /C 'U. ''l' <br /> ti[ /'�c.Gs L[C/G rL� L C! �, {'✓Gc d W <br /> cA.0" L eA /vll C /N ti,tr <br /> TIME RECEIVED /7.� TIME OF ARRIVAL a- 19 TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME rA.�GENCY PHONE NO. TOA TOD <br /> M[Tf lius -601 <br /> !'7 S l9 >S9 <br /> /S / <br /> IDENTIFICATION OF MATERIAL (CHEM ICAL INVOLVED) SC' <br /> SUBSTANCE FORM: L] SOLID [ ] POWDER [ ] GAS Vj QUID I GRANULE <br /> REFERRALS TO: DATE MA]LED: <br /> DATE COMPLETED: PROP 65 �2 07 — 9 3 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ ] 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 [4MAP [a/FILE CREATED <br /> A DiWsioo of bn Joaquin Count'Health Care Semm �� <br />