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Environmental Health Department <br /> S li San Joaquin County <br /> ,+ 304 Weber Avenue,Third Floor <br /> ¢� Stockton,CA 95202-2708 <br /> cs Emergency Reporting Form <br /> �FJThis form must be returned to Environmental <br /> Health Department within 15 days after the <br /> emergency has occurred. <br /> Name/address of Owner/Operator: PSXP Inc. <br /> P.O. Box 3469 <br /> Modesto, CA 95353 <br /> Telephone of owner/operator: 1-209-549-9274 <br /> Name/address of location: Prime Shine Wash n' Lube <br /> 301 W. Kettleman Lane <br /> Lodi, CA 95240 <br /> Date of incident: <br /> Time of incident: <br /> Details of Incident: <br /> Name and quantity of materials involved: <br /> Injuries: <br /> Is there any actual or potential hazards to human health or the environment post emergency?: <br /> What is the estimated quantity and disposition of recovered material that resulted from emergency?: <br />