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ALTH SERVI'(4,ESPUBLIC <br /> SAN JOAQUIN COUNTY <br /> ENVIR01``+iENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer �,Cijcpit��r <br /> 445 N. San Joaquin Sn-eet • P.O. Box 388 a Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> MIERGENGY RESPONSE RECORD SHORT TERM# <br /> DISTRICT # DATE �gf <br /> CITY 5�4J�Ga4QL-y Cra. <br /> PRENUSE ADDRESS 9 <br /> DBA <br /> P REMISE OWNER <br /> OWNER'S ADDRESS �Y`�ov //4�Y Z <br /> o <br /> PH <br /> FACILITY <br /> 0 79a <br /> FACILITYCONTACT �� "� or abandanedJ'd�Ped material) <br /> NATURE O CO LAINT (explosio�. , <br /> 3� TlhhC OF DEPARTURE <br /> 11ME RECEIVED . 6 3 _TUC- OF ARRIVAL (TOD) <br /> (TOA) <br /> PERSONS AT SCENE PHONE NO. TOA TOD <br /> NAME AGENCY <br /> Galei � ; Z� o Igo <br /> �-varinl G ti9�F —�,�r� <br /> IDENTIFICATION OF MATERIAL. (CHEMICAL 10MVED) n <br /> oma„ o5G✓Q'� �.YJi'iS- <br /> SUBSTANCE FORM: SOLID [] POWDER [ ] GAS <br /> LIQUID [ ] GRANULE <br /> DATE MAILED: <br /> REFERRALS T0: ` <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED ADDRESS PHONE NO. <br /> NAME <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? 17 `-'F-S N�,-,NO <br /> E.R.BINDER COPIES: <br /> . ROP 65/UAR <br /> C�SHORT-TERM ATTACHED ON TOP �NARRA'FIVE [ ] ANALYTICAL DATA ' ' .` <br /> ( ] EXPOSURE RECORD [ ] yfANIFEST I ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> ] Ry----PRALS 1 iP.P [ ] FILE CREATED <br /> .� ()i,won of San Soayuin County Health Cure Senic- <br />