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PUB9C HEALTH 0.,.9.14!. <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D., M.P.H. <br />Health Officer <br />P.O. (lox 2009. (1601 East Hazelton Avenue) • Stockton, California 95201 <br />(209)468-3400 <br />EMERGENCY RESPONSE RFMRD <br />DISTRIcr # 3a DATE �r�—(r ST # 9/b5` y� <br />PREMIS. <br />PREMISE OWNER <br />ADDRESS <br />FACILITY CONTAcr <br />NATURE O y COMPLAINT (explosion, pill, leak fire, or abandon/dumped maters l) <br />COMPLAINANT ::�e 4iqQqAGENCY PIIONE NO. <br />"TIME RECEIVED.3 D TIME OF ARRIVAL_TIME Ur DEPARTURr.. <br />0Y01)) <br />PERSONS AT SCENE <br />NAME AGENCY PRONE.. NO. TOA TOD <br />IDEN"11FICATION Or MATERIAL (CIIEMICALINVOLVED) <br />SUBSTANCE FORM: (J SOLID [ ] POWDER (] GAS (J LIQUID (] GRANULE <br />REFERRALS TO: DATE MAILED: <br />DATE COMPLETED: PROP 6.5 <br />PERSONS EXPOSED and/or INJURED <br />NAME. <br />INVESTIGATION <br />Mn /- , _j <br />FILF CR.F.A7IT1) [] <br />ADDRESS <br />RT (INCLUDE FINDINGS, CLEAN-UP, <br />eye 1-4 `C a'j, .0- T, <br />MAP INCLUDED <br />UAR <br />m <br />PHONE NO. <br />SIIORT-TERM AITACIIED [%; ER FILE COPY (� <br />A Division of San Joaquin County Health Care Services 0 <br />