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vSan Joaquin County DIRECTOR <br /> o Pquin/ c Donna Heran, REHS <br /> �...L .OG Environmental Health Department ASSISTANT DIRECTOR <br /> 600 East Main Street Laurie Cotulla,REHS <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> Cad Borgman, REHS <br /> ,. alp <br /> lrFOq Website: www.sjgov.org/ehd Mike Huggins,REHS,RDI <br /> Margaret Lagodo,REHS <br /> Phone: (209)468-3420 Robert McClellon,REHS <br /> Fax: (209)464-0138 Jeff Carruesoo,REHS,RDI <br /> I� C' EMERGENCY RESPONSE RECORD/ KaseyFoFoley,REHS <br /> DATE: ` AA SHORT TERM#: C 0 D U,3 3(O —b r <br /> PREMISE ADDRESS: S?O W r K G A CNL LA <br /> C ITY: dG t[�1Lll� <br /> DBA: �e r6o'-i gasp I C I f L <br /> PREMISEOWNER:_h0Fh&-dJ "1#0I 44L 6 �+ PHONE: (—Zoe?) 5K4 — cym-) <br /> OWNER'S ADDRESS: �-2 '1// W" 1A/-" C. � y/ , i rl �DLGL�N / G <br /> FACILITY CONTACT:_('VM1 17, V,O-C, N�"_�G"-"-�^ I— PHONE: (Zt�) L4&� — 3I GLI <br /> RESPONSIBLE PARTY(RP)DBA: N 4"gk' (� "Oty<�IVV�b f c�TOG��� Sic ArL'/n, z-%- q <br /> RP NAME: V f P� d� l " ��" PHONE: !60` �/ <br /> RP ADDRESS: Z�(] �dl'Cl"/T r. VpC V'k11.'J <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped materiae <br /> C an) rn1 v�J �uaA I r2(�� iGGv► <br /> V Nr 2 14 VA �h <br /> , -), <br /> TIME RECEIVED: ` <br /> •J 1 AtM. TIME OF ARRIVAL: D O�o k}I' t TIME OF DEPARTURE: I r 2<3 4A-� <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Br Iep6 Cos '�J9S� 3277 9;04* 5;204 <br /> err AAI wAgk, KV, <br /> N ! / — <br /> r <br /> IDENTIFICATION OF MATERIAL raawcu.w LVEDD Tr A7•v S M>f t%N r I V)6. C Tr x►��/N� <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS 5?�IdQUID ❑GRANULE <br /> REFERRALS TO: DATE MAILED: <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 /> ME. BI DER COPES : <br /> HORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA PROP 65/UAR <br /> ❑ EXPOSURE RECORD MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS 'tR MAP ❑ FI.E CREATED <br /> Documeetl Page: I of'3 6114/1999 <br />