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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> '7 �7 EMERGENCY RESPONSE RECORD <br /> DATE /G /y � , SHORT TERM p <br /> PREMISEADDRESSOS-l41/DDRESSS /-!�/� IJ W O' Za" 7�uN>aa.nl�wSe pl'Wv CITY T/L.(1/ <br /> DBA <br /> PREMISE OWNER q ( PHONE 240t) 3s-9y9 <br /> OWNER'S ADDRESS Z35-77 tj <br /> FACILITY CONTACT (fAar te6 S a f PHONE ZOg A3S- `3 V?I <br /> RESPONSIBLE PARTY(RP) DBA � / Oil2 H e CcN+ <br /> 2 !vt <br /> RP NAME • (D5u � Fret PHO 9l 75 70/57 <br /> RP ADDRESS ?360 &i C ko--1a:tn fjSbjAf.9 CA 99OK55 <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire,or abandoned/dumped material)p <br /> �i tri e t�� 501 r3 �Z 400 9ct(ldrt� <br /> TIME RECEIVED Jd 5 TIME OF ARRIVAL /2. 00 Ir?w, TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 0z0 <br /> 0zs) 764- )Z67 <br /> > u IA a� @ 3 — t 3 s :ao ,30 <br /> tj .tu„rnMevl <br /> 9! 371 - 72o-Z <br /> IDENTIFICATION OF MATERIAL(cxErn,cu.wvotveo) ❑ GRANIJI,E <br /> SUBSTANCE FORM [3 SOLID ❑ POWDER [I GAS �IQIDD <br /> DATE MAILED <br /> REFERRALS TO <br /> DATE COMPLETED........PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> .,PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E. R.BINDER COPIES: <br /> [:I SHORT-TERM ON TOP [I NARRATIVE ❑ ANALYTICAL DATA ❑ PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS ❑ MAP ❑ FILE CREATED <br /> A Division oFSan Joaquin County Health Care Services 6/14/1999 <br /> EH22014Lev.doc <br />