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( PUBLIC HEALTH SERVICES <br /> SAN JOAQliIN COUNTY <br /> JOGI 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 /> q/ EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE SHORT TERM# CnGt7/SOL <br /> PREMISE ADDRESS 677 Gv G SO CITY KTO� <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS ]} r <br /> FACILITY CONTACT IQNI��i�j C fgr�r + dg PHONELZ�) <br /> NATURE OF COMPLAINT (explosion, spill, leak, fire,or abandoned/dumped material) <br /> //LSE -V� 57Z)c,� 4DOe!z /41 r- ..---•— <br /> TIME RECEIVED " S�'�D�`y TIME OF ARRIVAL"_g=�c7Owi TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> N AGENCY PHONE NO. TOA TOD <br /> CAP71 151f4ld •• <br /> G� 44.7-- <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS [ ] LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 / - - _ UAR A <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> PI/- <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES NO <br /> E.R.BINDER COPIES: <br /> [SHORT-TERM ATTACHED ON TOP LA<jNARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR <br /> [ I EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS MAP [ ] FILE CREATED <br /> A Division of San Joaquin Counry Health Care Services <br />