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SERVICES <br /> HEALTH PUBLIC <br /> SAN JOAQUIN COUNTY <br /> ENVMONI-_%aN- TAL HEALTH DIVISION <br /> Ernest M. Fujimoto, I.D., M.P.H., Acting Health Officer ��CiFoiet'�� <br /> 445 N. San Joaquin Sheet 0 P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 �00 1 <br /> EwERC�ICY RESPONSE RECORD SHOR TERM# <br /> DISTRICT# DATE �L <br /> criy <br /> PREMISE ADDRESS <br /> DBA <br /> J PHONE <br /> PREMISE OWNER <br /> OWNER'S ADDRESS 3 f. s -✓ <br /> PHONE L � <br /> FACILITY CONTACT ,Sbaadonecl/dumped mabcrial) <br /> NATURE OF CO (e SP <br /> Illy -or. <br /> rf�'oZ�e+- TIME OF DEPARTURE 7 <br /> ��, . ,TIM£Or ARRIVAL {T D) <br /> TIME RECEVED (TOA) <br /> PERSONS AT SCENE AGENCY PHO NO. TOA TOD <br /> NAM <br /> MENi'IFICATION OF MATERIAL {cNEMICAI Ir4Mx) <br /> SUBSTANCE FORM: [] SOLID [1 POWDER [] GAS <br /> LIQUID [] GRANULE <br /> DATE MAILED: <br /> REFERRALS TO: <br /> UAR <br /> DATE COMPLETED: <br /> PROP 65 <br /> PERSONS EXPOSED and/Or 2 UAED &DI ESS PHS NO• <br /> NAME <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE 3ECORD' COMPLETED? (] <br /> YES [1 No <br /> sy R ER COPIES: <br /> SHORT-TERM ATTACHED ON Top/el" <br /> OP ]N.aRRATZVE C] ANALYTICAL DATA PR <br /> OP 65/UAR <br /> [ 3 <br /> []QST C] CLEANUP FIRM REPORT [] OTHER AGENCY REPORTS <br /> EXPOSURE RECORD <br /> C] REFERRALS C I ASAP C ] FILE CREATED <br /> pi.won of Sun 1t)ayuin County Health Care Servke. <br />