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PUBLIC HEALTH SERVICES _,aA <br />SAN}OAQUINCOUNTY <br />JOG] KHANNA M -D . M1H. !, <br />Health Officer <br />C <br />P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br />(209) 468-3400 <br />E 1 'AGENCY RESPONSE RECORD <br />6 —1 <br />DISTRICT # <br />DATE <br />SHORT TERM # <br />PREMISE ADDRESS <br />�_�D <br />DBA <br />PREMISE OWNER �� SV C�,ePo r�bN _ PHONE 7 S SZJ 0 <br />OWNER'S ADDRESS / ' �• �/` %�-Y G� T ���7� <br />4 <br />FACILITY CONTACT�� v J �C✓��G�,� - PHONECZ )'g <br />NATURE OF COMPLAINT (explosion, sp , leak, fire, or abandoned/dumped material) <br />/AG OIC d vN �EIEE9 �T <br />TIME RECEIVED q = 1 oI TIME of ARRIVAL __11 :_ _`%5tiwr TIME OF DEPARTURE 12 =�5 Q <br />(TOA) (T006 <br />PERSONS AT SCENE <br />NAME AGENCY PHONE NO. TOA TOD <br />IDENTIFICATION OF MATER[AL ( CHEM I CAL I NVOLVED) _ _ *J� )C7 Gpi i D <br />SUBSTANCE FORM: I I SOLID [ I POWDER [ I GAS `(LIQUID [ ] GRANULE <br />REFERRALS TO: /l /A— DATE MAILED: Alf /T - <br />DATE COMPLETED: PROP 65 ... _ _ �1 � ��� f2 UAR q <br />PERSONS EXPOSED and/or INJURED <br />NAME ADDRESS PHONE NO. <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ I YES [ I NO <br />E. R. BINDER COPIES: <br />[ ] <br />SHORT-TERM ATTACHED ON TOP [ j NARRATIVE [ I ANALYTICAL DATA PROP 65/UAR <br />[ ] EXPOSURE RECORD [ j MANIFEST [ I CLEANUP FIRM REPORT [ j OTHER AGENCY REPORTS <br />(] REFERRALS [ I MAP [ I FILE CREATED <br />A Dhtuan of fan Joaquin Cou,y He -Lith +:are bemccs 1(-) <br />