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oPa;k-� SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E Main Street Stockton • CA 95202 <br />(209) 468-3420 • Fax: (209) 464-0138 • mob: www.sigov.org/ehd <br />'4[%£ORit`P <br />EMERGENCY RESPONSE RECORD <br />DATE: <br />I <br />SHORTT'ER14LY: <br />C000 <br />ADDRESSE : /, 1 �/1 rl V . <br />'(/� V <br />CM: <br />� <br />DBA: <br />�V <br />PREMISE OWNER: <br />Gam: PHONE: <br />Da <br />OWNER'S ADDRESS: <br />14LKk re Pi MLCITY: <br />FACIITI'Y CONTACT: <br />PHONE: <br />}W— <br />RESPONSIBLE PARTY (RP)V <br />DBA: <br />CNN <br />RP <br />AME: <br />j 4 l Sr <br />I <br />PHONE: <br />M <br />V V <br />RP ADDRESS: <br />CITY: <br />RP CONTACT: <br />FHONE: <br />NATURE VN COMPLAIN I (eA oa, NM, leak, We, or aDanaonea/ a malenal) <br />-�kl� f4M UWLfd , Uhri o�- Saw Cu,�41? +4 Gt;J44i(l Cnvlv�W-'- -Grr <br />,re�� cpm a �sma�,�t►�tvid s b" dziu�ed <br />RTIMETIME ECEIVED: ARRIVAL: OF I TIME OF DEPARTURE: <br />DFRCf1N4k AT IZPPNF <br />POWDER I I GAS <br />REFERRALS TO: <br />I <br />I DATE MAILED: <br />DATE COMPLETED .... PROP 65: <br />w7e V <br />Sam <br />PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />�ffmmm�=rl <br />YES <br />I NO <br />POWDER I I GAS <br />REFERRALS TO: <br />I <br />I DATE MAILED: <br />DATE COMPLETED .... PROP 65: <br />w7e V <br />UAR: <br />PTR nNC FXOhCRT) andl.r TN11TR7:.T) <br />NAME <br />ADDRESS PHONE <br />PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? <br />YES <br />I NO <br />ER RECORD MODIFIED Page l of 05/01/2007 <br />