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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer4.. <br /> (IFOR <br /> 445 N. San Joaquin Street + P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# DATE SHORT TERM # ; <br /> PREMISE ADDRESS CITY <br /> DSA0 ec�) + - _ <br /> PREMISE OWNER y�f� _ PHONE ( <br /> OWNERS ADDRESS t�-`E W <br /> FACILITY CONTACT � "` `''"" J- PHONE <br /> NATURE OF COMPLAINT (explosion spill, Imi,fire, or abandoned/dumped material) <br /> �(Q no- - <br /> TIME RECEIVED 3",Z _ TIME OF ARRIVAL TIME OF DEPARTURE 630-P <br /> (TOA (Tcd) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> i <br /> r <br /> IDENTIFICATION OF MATERIAL (CHEMICAL IriOtVED) <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER E ] GAS [ ] LIQUID [ ] GRANULE 1 <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> i <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ ] NO i <br /> E.R BINDER COPIES: <br /> DATA PROP 6S/UAR <br /> YARRATIVE ANALYTICAL, [ � <br /> SHORT-TERM ATTACHED ON TOP � C ] <br /> L ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORIS <br /> [ ] REFERRALS (,]' E ] FILE CREATED j <br /> A f},i,ion of San.luayuin Cuunty Health Lire Servic" <br />