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PUBLIC HEALTH SERVICES oP4��N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION a: <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer �•.. P <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> EIVIERGENCY RESPONSE RECORD <br /> DISTRICT# �Z DATE SHORT TERM #COOO l S1 I <br /> PREMISE ADDRESS g4z_'Dwex/o,'4 CITY /,dV G y <br /> DBA �YIa "_06.OAI / . <br /> PREMISE OWNER /P P• 5-r/Z3 4" /z PHONE <br /> OWNER'S ADDRESS S/..30 44Ae,1410 41641- dGW A1161&14. 5 <br /> FACILITY CONTACT /��r►1G/� /� PHONE <br /> NATURE OF COMPLAINT (explosion,40leak, fire, or abandoned/dumped material) <br /> ^ /OU 6r/lirr,4 /J"ace.-I '-, <br /> TIME RECEIVED // _5O a TIME OF ARRIVAL Il: n4+, 15/1ol9� TIME OF DEPARTURE (2:20 <br /> (TOA) (TOO) <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE NO. TOA TOD <br /> h%&Pvc PIZ.Aw ow. >rE rGiE 4� 3 <br /> w re';"If i Zoo <br /> �c rp�Vi E <br /> r i -16 Z <br /> IDENTIFICATION OF MATERIAL. (CHEMICAL INVOLVED) yUc� <br /> SUBSTANCE FORM: [ ] SOLID [ ] POWDER ( ] GAS [LIQUID [ ] GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED: PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE NO. <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? [ ] YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ATTACHED ON TOP [NARRATIVE [ ] ANALYTICAL DATA 'j PROP 65/UAR <br /> [ ] EXPOSURE RECORD [ ] MANIFEST [ ] CLEANUP FIRM REPORT ( ]\OTHER AGENCY REPORTS <br /> [ ] REFERRALS MAP [ ] FILE CREATED <br /> `�S A 1)ivision of San Joaquin County Health Care Senic" <br />