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RVICES OpQUIN' <br /> PUBLIC HEALTH SE <br /> SAN f OAQUIN COUNTY <br /> N; - <br /> IOGI KHANNA M.D.M.P H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT # 5r� DATE �J 97 SHORT TERM # <br /> PREMISE ADDRESS —/2/l��ie � 'le Nt A- i1 ^I CITY <br /> DBA <br /> Y � PHONE(;-Og) �GjG{� 60y3 <br /> PREMISE OWNER U n <br /> OWNER'S ADDRESS L L �0O N, t O�( qi S 3�(, <br /> FACILITY CONTACT DPHONE <br /> NATURE OF COMPLAINT (explosion, ill fir , or abandoned/dumped material) <br /> (-/ 1 3 Z-- <br /> TIME <br /> TIME RECEIVED l� ' �7 TIME OF ARRIVAL /L = �j�� TIME OF DEPARTURE <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME -AGEENNCYY PHONE NO. TOA TOD <br /> cfj /�4Z,0 G /� -P- <br /> G4.Q 5?bGG A6 . /�F�i F L 3- 930 <br /> 5.-�j . C O. ptb41- y (/6,8- 307q- <br /> IDENTIFICATION <br /> 07IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) b'4/J 32— <br /> SUBSTANCE <br /> 2— <br /> SUBSTANCE FORM: [ ] SOLID [ J POWDER [ ] GAS kLIQUID [ ] GRANULE <br /> REFERRALS TO: tV, 4. G •�/. DATE MAILED: n <br /> DATE COMPLETED: PROP 65 Z/ ���� UAR �I 1 <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES jr} NO <br /> E.R-BINDER COPIES: <br /> [SHORT-TERM ATTACHED ON TOP [-)'NARRATIVE [ ] ANALYTICAL DATA U-PROP 65/UAR <br /> [] EXPOSURE RECORD [ ] MANIFEST [ J CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> (i REFERRALS (y] MAP L,-T FILE CREATED <br /> A Division of San Joaquin County Hcalth Care ScmCcs IQ j <br />