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fi <br /> PUBLIC HEALTH SER-VICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION N <br /> Karen Furst, M.D., M.P.H., Health Officerp.. <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EIVIERGEi`CY RESPONSE RECORD <br /> �# :01 <br /> DATE Q U SHORT T r <br /> PREMISE ADDRESS CITY <br /> DBA <br /> PREMISE OWNER f PHONE <br /> OWNER'S ADDRESS U D Z30 �U <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DBA .J4 <br /> RP NAME PHONE <br /> RP ADDRESS <br /> i. <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> TIME RECEIVED -1 { TIME OF ARRIVAL <br /> S' b v TIME OF DEPARTURE '��' <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(cxSNIcAL SNVOLveD) L X <br /> SUBS TANCE FORM 1:1SOLID . ❑ POWDER ❑ GAS LIQUID A ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> i <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> I:., <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA �❑ PROP 65 1 UAR <br /> EXPOSURE RECORD ANIFEST 13CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS AP ❑ FILE CREATED <br /> Sx22014rev.doc A Division of San Joaquin Counry Healrh Care Services �� 6/14/1999 <br />