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1 . <br /> PUBLIC HEALTH SERVICES OP�U N C <br /> � o <br /> SAN JOAQUIN COUNTY <br /> JOG[KHANNA M.D.,N.P.H. ^_ <br /> Health Officer <br /> C P <br /> P.O. Box 2009 (1601 East Hazelton Avenue) • Stockton, California 95201 9 "O <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DATE /UZ6 DISTRICT#� SHORT TERM# <br /> PREMISE ADD.RE,SSS�L3�;A>E�/ A•VG CITY 3-/UG- -21-25�I <br /> DBA , ` <br /> PREMISE OWNER ��/r/ /'Y7✓F.,�`T����/y�/ �fW'F-��Y PHONE !�J - "� 7� <br /> OWNERS ADDRESS ��/y �^ ,1/�� _ AV� 5`T-„IG-nrW 4:.4 25 Z-& <br /> FACII.I'IY CONTACT PHONE-!�(Z S -a 76 Z <br /> NATURE OF COMPLAINT (explosion, spAl, leak, fire, or aban/d�oned/dtunped material) /� <br /> Sl�iG 2/1/ /�7 <br /> e/7-A1224- 5'7' <br /> TIMERECEIVED TIMEOF ARRIVAL / Ih Dlzi TIME OF DEPARTURE /�L <br /> (TDA) (TOW <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> �L�nt i i r A6nLT4 ojy— E�=E/-76` — <br /> 11AAje&ui-L5 alsoerl .� <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS [-LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 /f/� UAR <br /> PEjLSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD” COMPLETED? [ ] YES [4 NO <br /> E.R.BINDER COPIES: / <br /> [ ] SHORT-TERM ATTACHED ON TOP [-J NARRATIVE [ ] ANALYTICAL DATA [ ] PROP 65/UAR/CLEAN[JP MFR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [qeNIW [ ] FILE CREATED <br /> A Division of San Joaquin County Healrh Care Services <br />