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r� <br /> t <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> �.• .oG Unit Supervisors <br /> Donna K.Heran,R.E.H.S. Carl Borgman,R.E.H.S. <br /> Za 304 East Weber Avenue, Third Floor <br /> y. Director Mike Huggins,R.E.H.S.,R.D.I. <br /> ,Al OlsenR.E.H.S. Stockton, California 95202-2708 <br /> Douglas W.Wilson,R.E.H.S. <br /> • .• P Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> 61 \ <br /> Laurie A.Cotalla,R.E.H.S. Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager Mark Barcellos,R.E.H.S. <br /> n2 ( <br /> EMERGENCY RESPONSE RECORD � " I <br /> DATE 7i !�� 0 SHORT TERM# 0 DO d ` 3 ` <br /> PREMISE ADDRESS 5"bU t`''' u CITY FrtAU rA <br /> DBA ';P ��,Q✓� CSO ('512 t1Q1`vt. lei Cil✓i. <br /> J <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS n <br /> PHONE <br /> FACILITY CONTACT <br /> RESPONSIBLE PARTY(RP)DBA �S A(IJ xA4AAA --Q P <br /> PHONE <br /> RP NAME n ,� <br /> RP ADDRESS OL -, <br /> PHONE <br /> RP CONTACT <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) AS C &>.4i o / <br /> In Coy.- A <br /> TIME RECEIVED D t TIME OF ARRIVAL (( : D TIME OF DEPARTURE�2 3 0 <br /> PERSONS AT SCENETOA TOD <br /> NAME AGENCY PHONE I���S <br /> r, i �0 <br /> �— � YL, i-lb�— l�►�6 Ii;oS <br /> �usYD . l�;KS <br /> �. �•S P P <br /> %�- cer:oosA S D Iy!SOP ;K"S _ N <br /> IDENTIFICATION OF MATERIAL(CHEWay.uvvorveDU '��/ <br /> SUBSTANCE FORM El SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE O <br /> REFERRALS TO N�' U Pf w`'� Q 94 5 C L DATE MAILED <br /> DATE COMPLETED............PROP 65 3 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: err <br /> SHORT-TERM ON TOP KNARRATIVE ElANALYTICAL <br /> OTHER AGENCY REPORTS <br /> ANALYTICAL DATA PROP 65/UAR <br /> C1 EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT <br /> ❑ REFERRALS MAP kFILE CREATED <br /> 6/14/1999 <br /> EH22014rev <br />