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. PUBLICHEAD , SERVICES aaau�N .� <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,1M.P.H. �. <br /> Health Officer <br /> P.O. Box 2009 (1601 East Hazelron Avenue) • Scockcon, California 95201 <br /> (209) 468-3400 <br /> EMERGENCY RESPONSE RECORD <br /> DATE a(C'? DISTRICT# 3 a `� SHORT TERM# Q 1 SSG 7 <br /> PREMISE ADDRESS 3 gyp/ CITY ! � <br /> DBA P�r� 4 LAA-&e,. �YC.SIA"'W4 rC), <br /> PREI ESE OWNER + r Y1 GC 4[.C.J b 1�3" �--�' PHONE <br /> OWNER'S ADDRESS I " <br /> FACMX Y CONTACT <br /> NATURE OF CO LAINT (explosion, spill, leak, firs, or abandoned/dum t ) <br /> L G 'Yv <br /> l <br /> r <br /> TIME RECEIVED 1 Q TMM OF ARRIVAL FNO. <br /> TIMEOF DEPARTURE .3 <br /> (TOD) <br /> PERSONS AT SCENEM4jME AGENCY TOA TOD <br /> IDENTIFICATION OF MATERIAL (c L INVOLVE <br /> SUBSTANCE FORM: j/OLID OWNER [ I GAS C I LIQUID C I GRANULE <br /> RE.ERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 45 I a q 1 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COW. LHTED? [] YES NO <br /> E.R_BIIVDER COPIES: <br /> [U/9'HORT-TERM ATTACKED ON TOP [ I NARRATIVE CgANALYTICAL DATA /PROP 65/UAR/CLE4NUP WR <br /> [ I EXPOSURE RECORD [ I MANIFEST [ ] CL ANW FIRM REPORT [ I OTHER AGENCY REPORTS <br /> l�FERRALS [ I MAP VFIFILE CREATED <br /> A Division of San Joaquin County Health Care Services <br />..........., ..: .. .,,. .:r�:...5:r..:..�;:a•;;•;�r'.. -. ... . -, ., .............::i::.:::�::C.i::;:5.'::Fff15.r:rr :::u:.S.G� ;f _ ._.._. <br />