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SERVES <br /> PUBLIC�EALTH <br /> SAN JOAQUIN COUNTY — 1< <br /> JOGI KHANNA M.D.,H.P.H. <br /> Healch Officer c * - <br /> �idot+a <br /> p O. Box 2009 (1601 Easc Hazeelron Avenue) a Scockcon,California 95201 <br /> (_' 9) <br /> Ehff1MGENCY RESPONSE RECORD <br /> i SHORT TERM # <br /> DATE L'Z Z DISTRICT 0 <br /> CRY <br /> ,/ ,cam'- � <br /> PREMISE ADDRESS , C- T s7 / j�ylyGOPE�4�iNCr c'V . <br /> DBA t/�ct�v1�/ C <br /> 7 j/ PHONE <br /> PREMISE OWNER <br /> OWNE.4'S ADDRESS 7Z-�� <br /> FACILITYCONTACTS%`f �r�SiU•yCUPc�-T� e SUpf�✓'so/�� PxoNs <br /> losio spar leak, or abandoned/dumped material) <br /> NATURE of COnLAINT (�P i) ,� viicul C/3 90 �G / S i, r Y <br /> 7 : 9�o^, TIME OF DEPARTURE <br /> Tga RECEIVED l� T of ARRIVAL — (rco) <br /> <toni <br /> PERSONS AT SCENE PHONE NO. TOA TOD <br /> NA_�fE AGENCY �v fp�jG/7j� <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) ��� />ly�2o�yo�/G ,y,✓ir� <br /> SUBSTANCE FORM: 1 SOLID [ 1 POWDER L 1 GAS [-!'uQUm ( 1 GRANULE <br /> REFERRALS TO:" /: G ?A 7TSC C�`yUC �3 —DATEMAaYD: <br /> DATE COMPLETED: PROP 65 ��� /yZ UAR IAJJ4. <br /> PERSONS EXPOSED and/or INJURED ADDRESS <br /> PHONE NO. <br /> NAME <br /> i <br /> *PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? L 1 YES <br /> E R.BINDER COPIES. <br /> SHORT-TERM ATTACHED ON TOP /NAR.RATIVE C 1 ANALYTICAL DATA `pROP MFR <br /> (I EXPOSURE RECORD CI CI CLEANUP FIRM REPORT CI OTHER AGENCY REPORTS <br /> C 1 REFERRALS C I FILE CREATED <br /> A Division of San Joaquin Counry Health Care Services <br />