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UBL EALTH SEES ora <br /> (DpySAN)OAQU'IN COL'V"[Y <br /> Hath Office: cq = <br /> P.O. Box 2009 (1601 East Hazelton Avenue) • Stockton, Caldora 95201 <br /> (209) 468-5400 <br /> 7 EMERGENCY RESPONSE RECORD <br /> DATE l /� i 7 DISTRICT# J 2f \ SHORT TERM# Oj!�00SLI7, <br /> PREWIISE ADDR SS <br /> DBA rO'L5- <br /> PREMIISE OWNER Co'in� �.JLa �...cfa C C.PCa PHONE ZU Ex z.zl <br /> OWNER'S ADDRESS _ P. �j6 <br /> FACILITY CON TACT l G' O,,,-eJ { PHONE `�R Z-(Cl ZG 4, ZZ� <br /> NATURE OF COMPIAI rr (explosion, spa leap fire, or abandoned/d=ped material) .l <br /> ?S� P HCC a/J_.21�acP 77�. /hul wa ldi . A . ,Z c.G/ f1"C <br /> TIME RECEIVED �7 :bU�-TIME OF ARRIVAL ZI Sb r, TIME OF DEPARTURE <br /> (TOA) (TCO) <br /> PERSONS AT SCENE <br /> NjA.�fE AGENCY PHONE NO. TOA TOD <br /> 3 �3, oE5 e/[Q- 34 .G 2:ave 1113 P <br /> Z -1-77 o <br /> Ire, T�, 4Z., V46- <br /> / 35-SY a <br /> IDENTIFICATION OF MATERIAL (CHEMICAL IMLVEO) <br /> SUBSTANCE FORM: [ ] SOLID ( ) POWDER [I GAS � LIQUID I ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLz' _'D: PROP 6S UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> A-11,4- <br /> 'PERSONAL <br /> -1 ,4-'PERSONAL TOXIC SUBSTANCE E,(POSURE RECORD' COMPL'_7ED7 [ ] YES to NO <br /> E.IL BINDER COPIES: <br /> Q("JRT-TEILM ATTACHED ON TOP NARRATIVE [ ] ANALYTICAL DATA [] PROP 65/UAR/CLEANUP MFR <br /> [ ] 0POS'JRE RECORD I ] MAN= [J CLF_WUP FIRM REPORT [J OTHER AGENCY REPORTS <br /> J REFERRALS [)9 MAP [ ] FILE CRE4T°..D <br /> A Division of San Joaquin Cuunry Health Csre Services <br />