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PUBLIC HEALTH SE, <br /> SAN JOAQUIN COUNTY = Z <br /> /�� <br /> JOGI nHANNA M.D.M.P.H. � \J\I <br /> Heairh Officer ��-! • �.., <br /> P.O. Box 2009 • (1601 Eat Hazelton Avenue) • S(OcktO 201 <br /> LiFGfatavP <br /> (209) 468-3400 r - p <br /> EMERGENCY RESPONSE RECORD ` SHORT TERM # <br /> DISTRICT# DATE -;L/ / <br /> PREMISE ADDRESS ro 0 L,) CG+ u v y CITY <br /> DBA - <br /> i <br /> PREMISE OWNER /C Sviru /p <br /> / PHONE 10 & -_f,jS/ <br /> OWNER'S ADDRESS SOO 6. ) CC�ovrcLi Sf- �vc�L�.-�, C,411 � <br /> FACILITY CONTACT 14176- PHONE v' c/(P6 ` So)S-/ <br /> NATURE OF COMPLAINT (explosion, sp fire, or abandoned/dumped material) <br /> 0 6u '/ u cis e s u.Pf o� <br /> TIME RECEIVED L/P/7'7 TIME OF ARRIVAL :?6 TIME OF DEPARTURE .S•• O,,yAZ <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY _ PHONE NO. TOA TOD <br /> ZoAgqo A 40 <br /> pig 9 <br /> S 3O <br /> I 5 <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) ct/k C' r d o / <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ I GAS [ QUID [ ] GRANULE <br /> REFERRALS TO: DATE MA=: <br /> DATE COMPLETED: PROP UAR -2-,/5-If <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES [ I NO <br /> I-R-BINDER COPIES: � <br /> [ SHORT-TERM ATTACHED ON TOP [TNARRATIVE [ ] ANALYTICAL DATA ["/ROP 5/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ]CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ ] REFERRALS [& MAP ['1 ii CREATED c. -a ...k /r <br /> A Divlvon of Vn Joaquin Co ly Ho1N C.M�m <br />