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PUBLi HEALTH SERV ICES oaa� N <br /> SAN JOAgUIN COUM =: <br /> JOGI KHANNA SI.D.,M.P.H. <br /> » � + <br /> Health Officer cq �o <br /> P.O. Box 3009 . (1601 Easr Hazelton Avenue) • Stockton,California 95201 crR ie <br /> (209) <br /> CStEMERGEY REO�RECORD CONFIDENTIAL <br /> DATE 9 L DISTRICT# 3 2 5- SHORT <br /> PREMISE ADDRESS VS-01 C--. CG ire. Ar4 CITY <br /> DBA Airia d.�r C�ii�-.rcc PREMISE OWNER OWNER l Sa .. t \ PHONE 7oy–Y(o 6–o0d /c <br /> OWNER'S ADDRESS 10"o'BOF Soob . S/v t EfrJr CA CIS Zoe <br /> FACImcoNTACT ke/a #c.,--e PHONF__�U9–�/fo(e da/S <br /> NATURE OF COMPLAINT Cez loriott s�eak, fire, or abandoned/dumped material <br /> �' i1 %(ed or was /�c s�.c� wry we �rfl <br /> iS �ti0 /�. .� ui,.r cr« <br /> TAME RECEIVED TME OF ARRIVAL TIME OF DEPARTURE p <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> rn C m . 'ad /KSe on s/ <br /> 27 <br /> �� rr rn crs O,Es- U•L9-'34/0 <br /> /�iee•rV/ OLa S.T/OHS VC/0 a:Go'" �a=T fir. <br /> IDENTIFICATION OF MATERIAL (CHEMICAL 110VOLVEo) �u�i�y�claviG /��ld <br /> SUBSTANCE FORM: [] SOLID// L l POWDER [ ] GAS Itl5Q-(JID [ ] GRANULE <br /> REFERRALS TO: C°.9<, PR/?SL� DATE MAILED: 2— <br /> DATE <br /> DATE COMPLETED: PROP 6S UAR N/r4 <br /> PERSONS EXPOSED and/or INJURED l <br /> <br /> <br /> <br /> <br /> <br /> <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? ( ] YES [ ] NO <br /> E.R.BANDER COPIES: <br /> HO •TERM ATTACHED ON TOP [q NARRATIVE L ALYTICAL DATA [ RO 6�5 UAR/CLEANUP ICIER <br /> [ OSURE RECORD L ] MANIFEST L ] CLEANUP FIRM REPORT /[ ] OTHER AGENCY REPORTS <br /> [ REFERRALS L7 I ] FILE CREA 01 YCr�.y!(p.tKYrlt <br /> A Division of San Joaquin County Health Care ices O <br />