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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer .. <br /> FQRea <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> E`IERGENCY RESPONSE RECORD ''tt <br /> DATE SHORT TERM# <br /> PREMISE ADDRESS �l� I`—� �Q CITY <br /> DBA P H 0 q—I'Z' 5, 7 <br /> PREINIISE OWNER POC. fl L Q `pa <br /> OWNER'S ADDRESS WDO �1 � � �� <br /> PHONE <br /> FACILITY CONTACT <br /> RESPONSIBLE PARTY (RP) DBA <br /> PHONE <br /> RP NAME <br /> RP ADDRESS <br /> PHONE <br /> RP CONTACT <br /> NATURE OF COMPLAINT(explosion, spill, leak, tire, or abandoned/clumped material) <br /> e <br /> TIME RECEIVED �j:U C1� TIME OF ARRIVAL 3o�sM TIME OF DEPARTURE �''OO�YYV1 <br /> PERSONS AT SCENE AGENCY PHONE TOA TOD <br /> NAME D <br /> (',VL►�Is A �.�I I Mor cw�, - <br /> l7a�v�Jc�.�-I�Son_ ��.00A <br /> a CA <br /> IDENTIFICATION OF MATERIAL(CHEWCAL!NVCLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POW R ❑�G��Q UID ❑ GRANULE <br /> DATE FLAILED <br /> REFERRALS TO I <br /> DATE COMPLETED........PROP 65 n UAR <br /> � <br /> PERSONS EXPOSED and/or INJURED -1-a P.n uran,v►��- <br /> PHONE <br /> NAME ADDRESS r <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD- COMPLETED? ❑ YES ❑ NO <br /> E. R. BINDER COPIES: <br /> ["SHORT-TERM ON TOP D JAINIFESTE El CLEAN TA S <br /> UP REPOICAL RT C1 OTHER REPORTS <br /> El EXPOSURE RECORD <br /> ❑ REFERRALS C� C1AP L�FILE CREATED <br /> a Division of San Joaquin Counts Health Care:er:ices <br />