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PUBLIC HEALTH SERVICES <br /> o�4��N..� <br /> SAN JOAQUIN COUNTY <br /> �. .o <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer .. P <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 #t''d 0 <br /> PREMISE ADDRESS `lam r <br /> DBA <br /> PREMISE 0 PHONE Ex l Z <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT Ute` <br /> NATURE OF COMP ( PHONE /' 3 �X (2 <br /> losion, spill, fire, ora doned/d material) <br /> TIME RECEIVED p..00A.�"�. 7/l r! TIME OF ARRIVAL TIME OF DEPARTURE <br /> Q <br /> PERSONS AT SCENE (TOA) (TOO) <br /> NAME AGENCY <br /> PHONE NO. TOA TOD <br /> _ OCA <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) .) (_.�(n')t� . C I CCC�o <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS [;.LIQUID [ ] GRANULE <br /> REFERRALS TO:I'(1&' )QCg PTSC. ' DATE MAILED: <br /> DATE COMPLETED: PROP 65_7b 7 s-- UAR <br /> r <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E. R. BINDER COPIES: <br /> SHORT-TERM ATTACHED ON TOP t4ARRATIVE [, ANALYTICAL DATA PROP 65/UAR <br /> I EXPOSURE RECORD &✓ MANIFEST [,,]/CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> C l REFERRALS [LMAP [ ] FILE CREATED <br /> A Dki%ion of San.Joaquin C mintti Health Care Scrvice. <br />