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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> )OGI KHANNA M.D.,NI.P.H <br /> Health Officer <br /> P.O. Box 2009 1601 East Hazelton Avenue) <br /> • Stockton, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# - � DATE -�'^�5-9 SHORT <br /> `TERM <br /> ^# <br /> PREMISE ADDRESS // I`/%�/ %i c 4`�,j / Cr1y <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACMITY CONTACT PHONE y b C7 - 00 <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br /> !/A r J / (C 4/ -A <br /> n 1 t 32 c c^'1 TBvIE OF DEPARTURE � I S >D <br /> TIME RECEIVED -I "��� TIME OF ARRIVAL <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> IDN�y 5233f 9+30 0 :/S <br /> Tckei 968. 341/ 9'30 . x:/54 <br /> Q. Sk. lir COS moo 9 . 30 a /./Sa <br /> f� bei lcy �' 3T- 972-S of la • /:/5f <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS Rub LIQUID (� [ ] GRANULE <br /> REFERRALS TO: 14P 1/ d ����a I DATE MAB.ED: Ru D <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 l NARRATNE [`7 AN LYTICAL DATA [ ] PROP 65/UAR <br /> [ ]/EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> lrl REFERRALS [4-MAP [L]-?LLE CREATED �1/o�'.cc. '� .4-Ac <br /> A Division of hn Joaquin(ounm Heal fare Xrvmces 1 <br />