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if <br />4 <br />PUBLIC HEALTH SERVICES <br />r,7U1N <br />SAIN JOAQUD COL -N -1-Y <br />ENVIRONMENTAL HEALTH DIVISION Q <br />Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br />304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 • °q� �.a.a' . <br />209/468-3420 <br />ESN ERGENCY RESPONSE RECORD <br />DATE SHORT TERM 4 <br />?REMISE ADDRESS L4n CITY <br />?REMISE OWNER bK r_Q ,_ ,mac . PHONE <br />OWNER'S ADDRESS Z--! �ntil <br />FACILITY CONTACT (� -� SIC ��r4 ritil F p PHONE <br />RESPONSIBLE PARTY (RP) DBA WE P- lA <br />RP NAIAE PHONE <br />?P ADDRESS q tel- S <br />RP CONTACT (' Y 0'. PHONE 599— a2'7Z <br />NATURE OF COMPLAINT (explosion, spill, leak, fire, or abandoned/dumped material) Iatv� V r1c):-, �-I <br />-� Qw 4 1 �,A <br />7LNE RECEIVED J Z.', 3a ;�tn_ TIME OF ARRIVAL� 2'. � o �vn TIME OF DEPARTURE ?;504 Yn <br />(TOA) (i OD) <br />?ERSONS AT SCENE <br />:DENTIFiCATION OF 'MATERIAL (CHE:MICALINVOLVED) `' , U (r TLo -S(A <br />SUBSTANCE FORM:' [ J SOLM ( J POWDER (J GAS [ ] LIQUID GRANULE <br />REFERRALS TO: <br />DATE MAILED: <br />DATE COMPLETED: PROP 6S -Lo - UAR <br />?ERSONS EXPOSED and/or INJURED <br />NAME ADDRESS PHONE 140. <br />'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES <br />E. R. BINDER COPIES: <br />SHORT-TERM ON TOP J)e NARRATIVE (] .-ANALYTICAL DATA <br />] EXPOSURE RECORD [ ] MANIFEST [ J CLEAN UP REPORT <br />] <br />REF=RP-kL.S FILE CREATED <br />EH ,- 014 4/96 <br />A Di%;sion or pan iva,;Uin Caunr. Health Care ,er. ices <br />PROP 66/UAR <br />[ ] OTHER AGENCY REPORTS <br />