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• <br /> ...... SAN JOAQUIN COUNTY • <br /> ENVIR7 <br /> %UT.AL HEALTH DEPARTMENT <br /> t96? fG 9treet Stockton - CA 95202 <br /> (209) 468-3420 - Fax:(209)464-0138 - Web:www.sigov.orci/ehd <br /> EMERGENCY RESPONSE RECORD <br /> DATE: AU011A FL ::FSHORT�TERM* 0000 <br /> PREMISE CITY: Loci 1, 1 <br /> ADDRESS: ? <br /> DBA: I <br /> PREMISE PHONE: <br /> OWNER: <br /> WNER: 0A 1 13 <br /> VS I CITY: <br /> OWNER'S ADDRESS: I L+ ©O kvj(&Q I?- <br /> FACILITY CONTACT: r 0 PHONE <br /> RESPONSIBLE PARTY (RP) <br /> DBA: I KbA sfocwyW v, OA <br /> RP 0 PHONE 3 6=4�-"6 <br /> NAME: <br /> RP ADDRESS441ci kujo> CITY: <br /> RP CONTACT: U t� as r PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) 153u C? Z 15 <br /> teleAsa -� cz n(twilll, -&r»n ^- rn <br /> - <br /> AA) <br /> 1;4y <br /> TIME RECEIVED: q TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Ottz,P- %A $vAor ht 'f)1V- l ,%,ofe <br /> R4 wc ;-V KOA <br /> 530-42s-A3 <br /> g !01 <br /> mala- 1-f P-7, M11, 30 <br /> v <br /> - ejav vj D�� �STC 4;5141> ��g (:3335 91. 2-6 <br /> IDENTIFICATION OF MAIAL(CHMM M LV D) ..-II <br /> SUBSTANCE FORM SOLID POWDER GAS IALIQUID <br /> REFERRALS TO: DATE MAILED: T 8GRANULE <br /> 1 !; /?-0 <br /> DATE COMPLETED....PROP 65: D 1 v UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? YES NO <br /> E.-R.BINDER COPIES: <br /> SHORT-TERM <br /> HORT TERM ON TOP NARRATIVE I ANALYTICAL DATA PROP 65 UAR <br /> EXPOSURE R�70S- <br /> RE IFEST I CLEANUP REPORT OTHER AGENCY REPORTS <br /> I REFERRALS YLMAP FILE CREATED <br /> ER RECORD ELECTRONIC VERSION Page 1 of 4 01/16109 <br />