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PUBLIC HEALTH SERVICES .o <br /> SAN JOAQUIN COUNTY <br /> a.• <br /> JOGI KHANNA M.D.,H.P.H. " < <br /> Health Officer <br /> �4C/Fp HN`P <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DATE 7/2 DISTRICT# 3.Zq SHORT TERM# 7110AY <br /> PREMISE ADDRESS 1601 TeAt- j ke Road crlY <br /> DBA Harbor S1pNs <br /> PREMISE OWNER 1,0,krcl. ♦"erLN¢- Y Malcol" FoAwf PHONE X09 - -'/67 - i 6/t, <br /> OWNER'S ADDRESS S3"e, as buSrNesS <br /> FACILITY CONTACT Lawn Garfu/ve- PHONE WQ( l- '/tiI-- !6/6 <br /> NATURE OF COMPLAINT (explosion, spIli, leak, fire, or abandoned dumped mater al) <br /> !3/ue l�ourc/ 2W-1�:.n P. 6N,%li�c , a�yu 41i <br /> fltc, 4-/art„ <br /> TIME RECEIVED 3:30 PM TIME OF ARRIVAL TIME OF DEPARTURE S : 119— <br /> (TOA) <br /> 19—(TOA) (TOD) <br /> .PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> LOuru Far/u.+e r-ac,fr et/ &yA)er, Ao? -e6h—/L/b orrie�.� wRn/ T atr;; I+Nknw/w/�+ <br /> v <br /> IDENTIFICATION OF MATERIA[. (CHEMICAL INVOLVED) 5'{Y.N/9d Y-//M ry fxye/ "IC. <br /> // / GU4�G <br /> SUBSTANCE FORM: [ ] SOLE) [] POWDER [ ] GAS [KLIQUID [ ] GRANULE <br /> REFERRALS TO: C.©.5- mq[ ' I WGI9' re'4ro/ Dld/sidry DATE MAII.ED: <br /> DATE COMPLETED: PROP 65 l.b1A UAR -� <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> AIONe- <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES CtelNo <br /> E.R.BINDER COPIES: <br /> / jo Nq <br /> E�l��}'-SHORT-TERM ATTACHED ON TOP [yNARRATNE [ ] ANALYTICAL DATA [ ] PROP 65/UAR/CLEANUP MFR <br /> /"[r]/EXPOSURE RECORD A4[] MANIFEST [ ] ,�C42ANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [WREFERRALS T'O U/MAP [ ]•FIE CREATED <br /> 0Q5 10',0 A Division of San Joaquin County Health Cue Services <br />