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PUBLIC�UALTH SERVItES <br /> SAN JOAQULN- COliNiY <br /> JOGI MANNA M.D., I.P.H. <br /> Health Officer r '� <br /> P.O. Box 2009 (1601 East Hazeleon Avenue) • Stockton,California 95201 <br /> (209) 468-3400 <br /> MdERGENCY RESPONSE RECORD <br /> DATE /.2 r r DISTRICT# SHORT TERM; r Z:t g/N <br /> PRENL'SEADDRESS c /1v✓. 50-4,,j JV' Z, _, CY_ -3 <br /> DBA_ NaVat COM91vteAiNs ;'f&170 w?el r. <br /> PRLwsF OWNER. Cr A.�N1`` er*1- PHONE O:/C n <br /> OWNER'S ADDRESS _ 6s- CL ef- <br /> FAC=CONTACT &VCC Q!!fS vcsl<l�n1t?'i^^� i� E" l.IPs'r PHONE - r?4Y-P--100 <br /> s <br /> .CPR- OF COMP (explosion, SPS leak. fire,or abandoned <br /> dumped materfal) <br /> 's� : 'e;// -4-1ark /A4 5�-1-+ a �,a. &'AleA -4IC;,✓4W ®.v7� <br /> cad rNc► 4� cLs c ,,H/.. <br /> MI"c RECEIVEIS"IZ3 d LAI Ma OF ARRIVAL 30 Am TMM OF DEPARTURE --i:3Z'PM <br /> CTOA) (TOO) <br /> PERSONS AT SCENE <br /> NA:titE .�1tN' E7' AGENCY PRONE NO. TOA TOD <br /> d 4` �O ?• yS o <br /> IDE.VZZFFCATION OFMATERIAL CCHEMICAL INVOLVED) <br /> SUBSTANCE FORA: [ ] SOLID [] POWDER [] GAS LIQUID [ ] GRANULE <br /> e <br /> REFS TO: DATE, <br /> DATE COWLMED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> /tlr8 :v,,C -e <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [] YES [s?"NO <br /> EYSHoRT-T-,xm <br /> BINDER COPIES: <br /> ATTACHED ON TOP (,/NARRATIVE [] ANALYTICAL DATA [] PROP 6S/UAR/CI.EANUP MFR <br /> 4 ] EXPOSURE RECORD14A,'`tLFEST [ ] CLEANUP FIRM REPORT [] OTHER AGENCY REPORTS <br /> M] REFERRALS [/MAP [ ] FILE CREATED [,/ -f i.3�tt"-oto.++ 14'-��d�^T <br /> A Division of San Joaquin County Health Care Services <br />