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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI nHANNA H.D..N.P.H. <br /> Heai[h Officer <br /> P.O. Box 2009 0 (1601 East Hazelton Avenue) 0 Stockton, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD /� C <br /> DISTRICT # AlATE b�I'Y-' .3 SHORT TERM <br /> PREMISE ADDRESS AI e_%or WI Oi��/C 9/'�`G!C�t �S I RCCC kc <br /> DBA <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS • , n /' <br /> FACILITY CONTACT I 1 CXJ'LC� (�;Ap S S 6 LyL <br /> NATURE OF COMPLAINT Cenilosion, spill, leak, fire, or abandotterl/dumped materiel) <br /> TIME RECEIVED g 1 3 b TIME OF ARRIVAL TIME OF DEPARTURE a 3 (� <br /> (TOA) (TOD) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> 1 G•C.aG <br /> � C11 g2 ,rte N+ G 1j: <br /> IDENTIFICATION OF MATERIAL (CHEMICAL INVOLVED) 05 <br /> `�S'D 1 vCt� d x-13-93 <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER [ ] GAS XI LIQUID [ ] GRANULE <br /> REFERRALS T0: DATE MAILED: /// ��\ <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ ] YES [ I NO <br /> E.R.BINDER COPIES: <br /> f 7'/6VORT-TERM ATTACHED ON TOP X NARRATIVE [ ] ANALYTICAL DATA PROP 65/UAR <br /> [ ] EXPOSURE RECORD `[ IIMANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHER AGENCY REPORTS <br /> [ I REFERRALS `�(J MAP [ ] FILE CREATED <br /> A Dmsro of fan Jnaquin Cmnry Health(are Se Cm C / <br /> I <br />