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i <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIItO\MENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto. NI.D., M.P.H., Acting Health Officer �r FORT <br /> 445 N. San Joaquin Sa-eec • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> EMERGENCY RESPONSE RECORD <br /> DISTRICT# <br /> DATE +4 C 5 SHORT TERM <br /> PREMISE ADDRESS Ei`4 ra el I 11 "1P CITY L Ci 1 1 <br /> DBA � � � Se <br /> PHONE <br /> PREMISE OWNER <br /> owNER'S ADDRESS f 741 <br /> 11 PHONE �'ZC�I� 73`�-�I�cF2 Pxt,IC <br /> FACILITY CONTACT <br /> NATURE OF COMPLAINT (explatuon, spa 1�12 ora �oned/dumped material) �.{ .1'tivm i Gr'ri C•') <br /> a �� r{�— <br /> J ` Q <br /> TIME RECEIVED ^js , TAE OF ARRIVAL /9 55 rim TIME OF DEPARTURE <br /> (TOA) (TDD) <br /> PERSONS AT SCENE PHONE NO TOA TOD <br /> NAME AGEN <br /> e. <br /> n <br /> } o <br /> � �P)nrrnme I S� �LraClnC- <br /> IDF_NTIFICATION OF MATERIAL (CHEMICAL !IM1OLVED) 1JI 11r I rr t v .�� <br /> SUBSTANCE FORM: SOLID C I POWDER C 7 GAS jQ LIQUID C I GRANULE <br /> bur,s -t reGz us es e� �-- <br /> REFERRAIS TO: I\�Ir} DATE MAILED: <br /> DATE COMPLETED: PROP 65 I1�15�G� UAR N`,I 4 <br /> <br /> <br /> 'PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD' COMPLETED? [ 7 YES P4 NO Fes-tictd.e SII r)CS5 <br /> .��st Qltachc� <br /> E.R BINDER COPIES: <br /> [ 7 SHORT-TERM ATTACHED ON TOP C I -1ARRATIVE C I ANALYTICAL DATA C 7 PROP 65/UAR <br /> [ 7 EXPOSURE RECORD C 7 MANIFEST C I CLEANUP FIRM REPORT [ 7 OTHER AGENCY REPORTS <br /> C 7 REFERRALS [] MAP C 7 FILE CREATED <br /> a!)i.i%iun of San .Iaayuin County Health Care Service% <br />