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PUBLIC HEALTH SERVICES <br /> SAN JOAQULN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION : <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 "CiFa'Ft�`P <br /> 209/468-3420 <br /> EMERGENCY RESPONSE RECORD n <br /> DATE '– – SHORT TERML tl <br /> PREMISE ADDRESS [mac/ CITY <br /> DBA F,� <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS _ <br /> FACILITY CONTACT 12 az( y1t PHONE <br /> RESPONSIBLE PARTY (RP) DBA R, V'ek <br /> RP NAME fie— PHONE –=00 <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, spill, k, fire, or abandoned/dumped material) <br /> C / 9 <br /> TIME RECEIVED J : 50 TIME OF ARRIVAL TIME OF DEPARTURE <br /> (TOA) <br /> (TO D) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> o r <br /> Lo rt S f <br /> /40 <br /> S rn C <br /> IDENTIFICATION OF MATERIAL (cmEmicu.urvocvEw <br /> SUBSTANCE FORM: [ J SOLID [ J POWDER ( I G S LIQUID [J GRANULE <br /> REFERRALS TO: y DATE MAILED: <br /> DATE COMPLETED: PROP 65 / f UAR 2'1 7_ /Cj <br /> 7 <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 ON TOP ARRATIVE [) ANALY'T'ICAL DATA PROP 65/UAR <br /> [ ] EXPOSURE RECORD ]MANIFEST [ ] CCLLE�C�A�D RT L 1 OTHER AGENCY REPORTS <br /> [ J REFERRALS -RMAP [ l <br /> EH 22 014 4/96 -R <br /> \ <br /> A Division of San Joaquin County Hr:ith Care err:ices <br />