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PUBLIC HEALTH SERVICES <br /> p0 U,l,y <br /> SAN JOAQUIN COUNTY r' <br /> Z <br /> JOGI KHANNA M.D.,H.P.H. <br /> Health Officer _. <br /> CqP:. <br /> P.O. Box 2009 . (1601 Easc Hazelron Avenue) • Stockton, California 95201 c' oar <br /> (209) 468.3400 <br /> / EMERGENCY RESPONSE RECORD <br /> DAiE DISTRICT 326 SHORT TERM# <br /> S <br /> PREMISE ADDRESS / g 0 0 8 W (-k or H Ag- A ty CITY bek4ALQe, 9 S3 3 u <br /> DBA v K <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS U K <br /> FACILITY CONTACT )K PHONE <br /> NATUREOF COMPLAINT (explosion, spa leak fire or abandoned/dumped material) <br /> 3Uynnr� b RP(�S 0.h � �/L ON � ONhd <br /> VIE RECEIVED = OF ARRIVAL �D �S TIME OF DEPARTUP.E <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> Lam, —0-T d 8, 07 M <br /> 6e a - 9 /a:L/0 A Al <br /> / R <br /> ( <br /> F 0 - S <br /> -4114/- f/40M <br /> Btr-L.�/n. tr S �< �Git-G_ S 1-o9—`lYb�7b'�-U //=✓1 <br /> IDENTIFICATION �F fATEF CHE CAL OLVED) <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 /> NAME n ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES 11 NO $f /UA <br /> E R BINDER COPIES: <br /> DQ SHORT-TERM ATTACHED ON TOP [ ] NARRATIVE [ J ANALYTICAL.DATA [ ] PROP 65/UAR/CL.EANUP MFR <br /> [ J EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ J OTHER AGENCY REPORTS <br /> [ ] REFERRALS [ ] MAP [ ) FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />