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fh <br /> E <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> :F 600 E Main Street Stockton s CA 95202 <br /> (209)468-3420■Fax.(209)464-0138 - Web:www.sjgpv.pr2/ehd <br /> 4{1i=oR� <br /> EMERGENCY,RES„PO}JSE.&ECORD„ <br /> DATE: �� 3(^ �! SHORT TERM#: CO003 6'7 S <br /> PREMISE2 r ^ny CITY: <br /> ADDRESS: <br /> li <br /> DBA: �~ <br /> 00 <br /> PREMISE �� PHONE: <br /> OWNER: rIG <br /> OWNER'S �- CITY: <br /> i ADDRESS: y- <br /> 'h FACILITY PHONE: <br /> CONTACT: <br /> RESPONSIBLE PARTY (RP) <br /> 1 DBA: C <br /> RP NAME: 1 PHONE: <br /> I <br /> RP <br /> CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> ,� CONTACT: <br /> NATURE OF COMPLAINT ex losion, spill, leak, fire, or abandoned/dnm d material) <br /> !.g TIME $��� TIME OF ARRIVAL: C�� TIME <br /> RECEIVED: r D� DEPARTURE: r <br /> i <br /> PERSONS AT SCENE <br /> p NAME AGENCY. PHONE TOA TOD <br /> i <br /> h <br /> IDENTIFICATION OF MATERIAL(CHEMICAL ZNVOLVED) <br /> i <br /> SUBSTANCE <br /> FORM LID <br /> D POWDER GAS LIQUID GRANULE <br /> i <br /> I <br /> REFERRALS DATE <br /> TO. MAILED: <br /> DATE COMPLETED....PROP UA <br /> 65: R.- <br /> PERSONS <br /> :PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> (At, m� <br /> ' I <br /> f <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD” COMPLETED? YES K NO <br /> I� ER RECORD MODIFIED Page 1 of 4 05/01/2007 <br /> .i <br />