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PUBLtC SE11VICES pully <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D., M.P.H. tn: I, <br />Health Officer <br />c•. •P <br />P.O. Box 2009 • (1601 East Hazelton Avenue) ® Stockton, California 95201 <br />(209)468-3400 <br />EMERGENCY RESPONSE RECORD <br />DISTRICT # (7 <br />PREMISE ADDRESS 32 d <br />DDA r F ;. <br />PREMISE OWNER fc,,� -c- <br />ADDRESS ZZ E ?'o kat <br />FACILITY CONTACT Rrml(�t�r <br />NATURE OF COMPLAINT( losion, spill, leak, fire, or abandonldrunped tnarefial): <br />TIME RECEIVED _. -j-,% { M TIME OF ARRIVAL PtA TIME OF DEPAR'JURI.- 3 r 0 pm <br />PERSONS AT SCENE <br />NAME A ENCY PHONE NO. TOA '101) <br />IDENTIFICATION OF MATERIAL (CIEMICALtNVomm)_u 9 afi' <br />SUBSTANCE FORM: [ I SOLID [ I POWDER [ I GAS KLIQUID O GRANULF, <br />REFERRALS TO: " DATE- MAILED: <br />DATE COMPLETED: PROP 6.5 — UAR <br />PERSONS EXPOSED and/or INJURED <br />NAME ADDRESS <br />INVESTIGATION REPORT (INCLUDE FINDINGS, C,FAN.UP, <br />FILE CREATED [ I <br />MAP INCLUDED [ I <br />SILO TIERM A-I1AC.'IIM <br />A Division of San Joaquin County Fdealth Care Services <br />PHONE NO. <br />