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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton,■ CA 95202 <br /> (209)468-3420•Fax:(209)464-0138■ Web:www.sjgov.org/ehd <br /> 4;f FOR <br /> EMERGENCY RESPONSE RE.00_111) <br /> DATE: SHORT TERM#. COOO 7'4!51 S <br /> PREMISE CITY: <br /> ADDRESS: l�6 T� �� R '`•' lh` CID <br /> DSA: I vt 1Mayi <br /> PREMISE ,It!v � � PHONE: S r <br /> OWNER: V + <br /> OWNER'S0041 <br /> 0 r 1 I CITY: <br /> ADDRESS: [9 'T' �L�,(�/'V DK <br /> FACILITY _ ` r PHONE: <br /> CONTACT: 0�•�/1 J <br /> RESPONSIBLEPARTY (RP) ` <br /> DBA: UNwV, <br /> RP NAME: PHONE: <br /> RP CITY: <br /> ADDRESS: <br /> RP PHONE: <br /> CONTACT: <br /> NATURE OF COMPLAINT(ex losion, spill, leak, fire, or abandoncd/dum ed material) <br /> oak kuW (VW4,t — 20 fW� ut.e.Q, <br /> TIME <br /> RECEIVED: Z' dU TIME OF ARRIVAL: �jd DEPARTURE: OF <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE SO POWDER GAS LIQUID I GRANULE <br /> FORM I t LID <br /> REFERRALS DATE <br /> TO: MAILED: <br /> DATE COMPLETED....PROP UA <br /> b5: R: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> ER RECORD MODIFIED Page 1 of 05/01/2007 <br />