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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY = _ <br /> JOGI i;HANNA M.D..M.P.H. <br /> Health Officer <br /> iq 1P <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 ons <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT # DATE � �� SHORT TERM <br /> PREMISE ADDRESS /`+ OBD,AN• ,1 CITYDBA �/ p�✓E�' Y 416btGA—L—'r/r`=— <br /> PREMISE OWNER 6 +51 >34 PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, spill, leak fire, or abandonnay�/dumped material) <br /> 07�J25 fin! ?eZ1 - SE E S/c 6`rrfb <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE I30 <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> EcK K ze 8,fT4=Ax* 3 - 552 3,0 <br /> Vc_ S7Yd.4� .V A4"-/ <br /> IDENTIFICATION OF MATERIAL. (CHEMICAL INVOLVED) / z <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER GAS ( ] LIQUID C I GRANULE <br /> REFERRALS TO: - DATE MAILED: <br /> DATE COMPLETED: PROP 65 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 [ I ANALYTICAL DATA C I PROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST ( ] CLEANUP FIRM REPORT ( ] OTHER AGENCY REPORTS <br /> [ I REFERRALS C I MAP [ 1 FILE CREATED <br /> 1 Diatislnn of vn laaaum C.wnm Hc+IN '.arc Ymm \� <br />