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PUBLIC HEALTH SERVICES �oP��o <br /> SAN JOAQUIN COUNTY <br /> JOGIKHANNA M.D.N11H <br /> Health Officer <br /> P.O. Box 2009 0 (1601 East Hazelton Avenue) 0 Stockton, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT # DATE Ll-17 SHORT TERM# <br /> PREMISE ADDRESS so CITY s�ck <br /> DBA vood or 1'eS5 rcragT-Aka'i ly 6 -Z76 <br /> PREMISE OWNER Ck d S PHONE L2oq g'<7' Y41 7 <br /> OWNER'S ADDRESS a Is S IF- &I a rck �_crit 5 �'AA ,.y� c-4 15207 <br /> FACILnY CONTACT PHONE 7- 17 <br /> 6a rg S <br /> NATURE OF COMPLAINT (explosion, spill, le* fire, or abandoned/dumped material) <br /> TIME RECEIVED S , LIS TIME OF ARRIVAL TIME OF DEPARTURE <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> Hrg 1 -3u `,re- q3 7-8_021 S 1&0,8 6 <br /> L4 6-9 <br /> %4 f28-- 033e 6,15 <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: SOLD) POWDER I GAS I I LIQUID GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> S <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? • YES NO <br /> E.R.BINDER COPIES. <br /> [-Z'S'HORT-TERM ATTACHED ON TOP NARRATIVE ANALYTICAL DATA PROP 65/UAR <br /> (�OSURE RECORD [/MANIFEST CLEANUP FIRM REPORT [J 'OTHER AGENCY REPORTS <br /> REFERRALS MAP FILE CREATED <br /> A Division of San Joaquin County Health Carc Services <br />