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PUBLIC HEALTH SERVICES �o <br /> SAN JOAQUIN COUNTY <br /> )OGI KHANNA MD.,M.P.H. <br /> Heaich Officer p- <br /> P.O. Box 2009 0 (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> c4�iFoga` <br /> (209)468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# 32 DATE Z Z$ SHORT TERM#C a� f o <br /> PREMISE ADDRESS Af /`r- X14� 4 my � <br /> DBAe:5� <br /> PREMISE OWNER -f e- G40 ^ PHONE(Za9) 111>4- 'R114 <br /> OWNER'S ADDRESS � 17�T Z I-- <br /> FACILITY CONTACT �/�? �S?�.�.- 4�/1i C 1 PHONE( 46t10'-) 46 --1�,Y <br /> NATURE OF COMP (explosion, spill, leak, fire, or abandoned dumped material) <br /> TIME RECEIVED `� _TIME OF ARRIVAL_I: 3a,J-t_ TIME OF DEPARTURE <br /> (TOA) (Too) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> Cw C.r 6 � rt <br /> IDENTIFICATION OF MATERIAE. (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS [ ] LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> AMIE ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ I YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-'PERM ATTACHED ON TOP [/NARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> ( ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ MAP [ ] FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />