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UIS'I'RICI' # <br />PREMIS <br />PULLIC HEALTH SIPRVICES oP......,� <br />SAN JOAQUIN COUNTY r. w <br />JOGI KHANNA M.D., M.P.H. U) X. ` <br />Health Officer <br />P.O. Box 2009. (1601 East Hazelton Avenue) Stockton, California 95201 c4�;Fop`'•P <br />(209) 468-3400 <br />EMERGENCY RCSPONSI? RIN ORD <br />il-S-�V <br />DATE S'I' #Y4 ::a) 5(5 0 <br />PREMISE OWNER <br />ADDRESS <br />FACILITY CON'I'ACI' <br />i¢y1.5-�rx�tir� c i <br />NATURE OFCOMPLAIN'T (explosion, spill, lez1fim, <br />material) fi.b S f �� ODO CIGhc,Q� <br />('OMPLAINANT AA/104169Z.5 AGENCY A")S Y; -PI IONS NO. <br />TIME RECEIVED 1!30a,,ti TIME OF ARRIVAL 11,C3 0 TIMI; OF DEPARTURE <br />PERSONS AT SCENE (7'0,4) qw)) <br />TOA TOD <br />IDEN'111-ICA'TION OF MATERIAL, (CHEMICAL INVOLVED) <br />SUBSTANCE I'ORM: n [ J SOLID (] POWDER (] GAS [ LIQUID (J GRANULE <br />REFERRALS TO: 10, k((Q� DQ S TSL P DATE MAILED: <br />DATE COMPLETED: PROP 6 5J — 1p q UARAJf4 <br />PERSONS EXPOSE -'D and/or INJURED <br />NAME ADDRESS <br />SHORT -17111M ATI'ACIILD [/ <br />A Division of San Joaquin County Health Care Services 40 <br />PHONE NO. <br />ER FILL? COPY [it/ <br />