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. too ws7 <br /> PUBLI HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> 0: N <br /> EIS VIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> �%FORM <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 &3 A CITY '_Sj s C" <br /> DBA � <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACII.I'IY CONTACT PHONE <br /> NATURE OF COMPLAINT (explosion, spill, leak, ora o dumped material) <br /> aTc <br /> TIME RECEIVED TAME OF ARRIVAL LI'G TIME OF DEPARTURE ��O <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> � C Q � <br /> IDENTIFICA4T �' (C E IAL INVOLVED) <br /> SUBSTANCE FORM: []`SOLD)/ [] POWDER [ ] GAS � LIQUID <br /> REFERRALS TO: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURID <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE DPOSURE RECORD" COMPLETED? [ ] YES [ ] NO <br /> E.R. BINDER COPIES: <br /> SHORT-TERM ATTACHED ON TOP /WYARRATIVE [ ] ANALYTICAL DATA PROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT [ ] OTHERS AGENCY <br /> .�cREPORTS <br /> [ ] REFERRALS [ I ]MAP [ I FILE CREATED 6t1, 1-vI � 5 /I )It <br /> WefS XPi f&0 <br /> > ;hhion or San Joaquin County Health Care Services <br />