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f <br /> PUBLIC HEALTH SERVICES <br /> POUIN <br /> SAN JOAQUIN COUNTY r. <br /> Q: <br /> ENVIRONMENTAL HEALTH DIVISION ".. , _7 <br /> Karen Furst, M.D., M.P.H., Health Officer �.. ..�P <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DATE ill-L&I0) �" SHORT TERM# GOOO1(•SS3 <br /> PREMISE ADDRESS to� L�C. CITY <br /> DBA l�� ��Lv+� -i <br /> PREMISE OWNERa PHONE <br /> OWNER'S ADDRESS .E'•�.� Foo &JZ� _ �5 � <br /> FACILITY CONTACTF'2�1-JQje <br /> PHONE 6 — S <br /> RESPONSIBLE PARTY P)DBA <br /> C� <br /> RP NAME St PHONE <br /> RP ADDRESS S f+T <br /> RP CONTACT . PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dum ed material) <br /> /CC)-zoo <br /> � ft-ruX ,o�R.tIL� <br /> TIME RECEIVED 9s Ot"��Q TIME OF ARRIVAL I L''��•'" TIME OF DEPARTURE l I • �C�iy�"� <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> .5tKk)• )_'-7 3 7- 8'600 <br /> t <br /> C7-C-- <br /> IDENTIFICATION <br /> TSIDENTIFICATION OF MATERIAL(CHEMICAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO I DATE MAILED <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> 4A <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED'? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ON TOP ,NARRATIVE ANALYTICAL DATA PROP 65 /UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST t CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS 0 MAP ❑ FILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />