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PUBeiC HEALTH SE 7ICES Q�q.••.•...� <br /> SAN JOAQUIN COUNTY / x, <br /> JOGI KHANNA M.D, M.P.H. :< <br /> Health Office: <br /> P.O. Box 2009 • (160I East Hazelton Avenue) • Stodaon, California 95201 <br /> (209) 468-3400 <br /> r� MvERGENCY.RESPONSE RECORD <br /> DISTRICT# DATE SHORT TERM # <br /> f i <br /> PREMISE ADDRESS <br /> �/ <br /> DSA �'• 6¢x-0 'L- ��, (I7 cc4► 1lNtiv r <br /> PREMISE OWNER PHONI- <br /> OWNER'S ADDRESS At I .C- M,424� G / ;0� <br /> FACILTIY CONTACT.�•d ` as.-�riv PHONE p <br /> OF COMPLAINT ( n, ill, 1 Cee pr ahando d ped material) i� <br /> � L�lj+ <br /> dr <br /> r <br /> TIME RECEIVED .L:*e R 4,t TIME OF AMVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> ' IDENTIFICATTON OF MATERIAL (i;HeBlcaR 1HVOLvED) ._�. .-�— — <br /> SUBSTANCE FORM: [ I SOLID POWDER [ ] GAS (`] LIQUID [ ] GRANULE . M <br /> REFERRALS TO: t DATE MAILED: <br /> 'I DATE COMPLETED: PROP 65 UAR k <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. i <br /> a i <br /> 1 <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E.R.BMER COPIES: <br /> j SHORT-TERM ATTACHED ON TOP ] NARRATIVE [I ANALYTICAL DATA [ ] PROP 65/UAR <br /> [ I EXPOSURE RECORD [ ] MANIFEST [I CLEANUP FIRM REPORT [ I OTHER AGENCY REPORTS <br /> [ I REFERRALS [ MAP [ ] FILE CREATED <br /> A Division of San Jtnquin fuunry Health r:im bemcrs <br /> r <br /> f <br />