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PQuIN <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY _` a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer .. P <br /> ,�rF ORa` <br /> 304 East Weber Avenue,Third Floor• Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE '�!��' Cs� � SHORT TERM# C O® U f S <br /> PREMISE ADDRESS R� � �C� I L1 CITY 5 IDC� f1 <br /> DBA Cili$ SfGt � Orx, <br /> PREMISE OWNER O tr f es^ L 0. PHONE <br /> oWNER's ADDRESS �^U �`nc.s C a r w <br /> FACILITY CONTACT /+ l Ii�r C t ��J�� PHONE7,'l ri 7� 7Z <br /> RESPONSIBLE PARTY(RP)DBA r CS}Z Q t^ <br /> RPNAME PHONE <br /> RP ADDRESS ^nn <br /> RP CONTACT 'y t `[i (c(&� a ei PHONE <br /> NATURE OF COMPLAINT(explosion,spill, leak, fire, or abandoned/dumped material) <br /> ���./ Qr,� � CL ,JLfLGCa� Sf� drl�.!'7�G.lZC••' �^%�- �rr-�LGeya.E�. O}Qre... <br /> TIME RECEIVED //,'0 D 9"^ TIME OF ARRIVAL ��`�Com^^ TIME OF DEPARTURE � 3 L <br /> PERSONS AT SCENE PHONE TOA TOD <br /> NAME AGENCY <br /> IDENTIFICATION OF MATERIAL,cxewcu wo ven UID ❑ GRANULE <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER [ILI GAS Q <br /> DATE MAILED <br /> REFERRALS TO <br /> DATE COMPLETED........PROP 65 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 ON TOP ❑ NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS ❑ MAP ❑ FILE CREATED <br /> A Nvisinn afSan loaauin County Health Care Services 6/14/1999 <br />