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r. <br /> PUBLIC HEALTH SER' ICES O.P4UtN:•.0 <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D..M.P.H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) •Stockton, California 95201 Cq C,F o•R`'�P <br /> (209) 468-3400 <br /> pl; G EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE U ' � SHORT TERM#Cb 0') <br /> 4'j L5 <br /> PREMISE ADDRESS 793o 3 o bt-j,/-4� L/►1�- Ra v-4 CNy <br /> DBA Zd "t�l��' (�(1 �C LFi✓ i2(—CN9� I?(J• �. <br /> � Q <br /> PREMISE OWNER I PHONE�GI� 83(7 <br /> OWNER'S ADDRESS I 1 , <br /> FACILITY CONTACT'l�l W)P- f�- ' PHONE 4 <br /> N OF,CO ( 1 'on, spi71, 1 o abandoned/dped mat ) _ <br /> D G <br /> TIME RECEIVED l:�O TIME OF ARRIVAL �- A ' TIME OF DEPARTURE 2 <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGEN - PHONE NO. TOA TOD <br /> tf <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) ,2.� <br /> SUBSTANCE FORM: [ ] SOLID �+ [ ] POWDER [ ] GAS LIQUID [ ] GRANULE <br /> REFERRALS TO: CV 2� &(-5 I 1 c"R., DATE MAILED: <br /> DATE COMPLETED: PROP 65��/�J 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 /> [ l REFERRALS MAP [] FILE CREATED <br /> A Division of San Joaquin County Health Care Services j <br />