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PUBLIC HEALTH SERVICES <br /> OPo'U.�N' C <br /> SAN IOAQUIN COUNTY <br /> Q: <br /> IOGI KHANNA M.D..M.P.H <br /> Heai[n Office: <br /> P.O. Box 2009 • (1601 Eau Hazelton Avenue) • Stockton, California 95201 c4Cf doR~�P <br /> (209)468-3400 <br /> '��t/� 1RG1?rICY RESPONSE RE <br /> DISTRICT # DATE:: CORD <br /> SHORT TERM#_ <br /> PREMISE ADDRESS O3gl0 ,A Gi- I--V O. ,Pa>., 6/z 7 CITY—��y <br /> DBA_./Ltd /_ ,rte <br /> PREMISE OWNER HSG f PHONE <br /> OWNER'S ADDRESS ZY41EIZ)AaA PAP>/ia4 v 71 �c 044_1Y <br /> LW4L f*Ge Sc.�FL'i2' ��l�V 3`-'(IAJ.d p' 57rEsy �'.''-��yr100 <br /> FACILITY CONTACT PHONE 684Z <br /> NATURE O COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED �/yg,�, Mm OF ARRIVAL_Fi 'G� c..z TIME OF DEPARTURE 9 oo cp i <br />' PERSONS AT SCENE (TOA) (TDD) <br /> NAME AGENCY . PHONE NO. TOA TOD <br /> TEii/4f1� :yo- ' nXr c. <br /> SrfL o ,57- G 3cr c <br /> F-. Zo3D <br /> IDENTIFICATION OF MATERIA, (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ 7 SOLID [ I POWDER E I GAS [ I LIQUID [ l GRANULE <br /> REFERRALS TO: itI/A DATE MAMED: ^4/A- <br /> DATE COMPLETED: PROP 65—,JI4- UAR /,J//f-- <br /> PERSONS <br /> J//--PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS <br /> PHONE NO. <br /> s��r; �.�;A' R36-NRa> 73�lii oo�if ocf':•- <br /> o F/ 54 <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES x NO <br /> E R.BINDER COPIES: <br /> CK SHORT-TERM ATTACHED ON TOP NARRATIVE [ I ANALYTICAL,DATA [ I PROP 65/UAR <br /> [ I EXPOSURE RECORD [ I MANIFEST [ I CLEANUP FIRM REPORT [I OTHER AGENCY REPORTS <br /> [ I REFERRALS 11�I MAP [ I FILE CREATED <br /> A Dnivon of fan JO2qum Counry He tN('arc) cm C 7 <br />