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O (�D� LJ <br /> ENVIRONMENTAL HEALTH)EPAR"wT <br /> 'o PgUlry CD SAN JOAQUIN COUNTY <br /> Q' y� Donna K Heran,RE.H.S. Unit Supervisors <br /> N. Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> - _ <br /> At Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,RE.H.S.,R.D.I. <br /> • e4.., . ,.,,�� S. <br /> Program Manager Telephone: 209 468-3420 Douglas t Wilson,R.E.H.S. <br /> F O e Laurie A.Cotulla,R.E.H.S. p ( ) Margaret Lagorio,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD Mark Barcellos,R.E.H.S. <br /> oc� <br /> DATE _ 7 �� n SHORT TERM# >�D 00 Z,N 7 1'I� sok. <br /> PREMISE ADDRESS 26? IC <br /> 00 Q A4U" O CITY 7rR A C, �__f J <br /> DBA P1 0 W 5 M^ R e LLC <br /> PREMISEOWNER _ PI 0NEE►L Cl t&;V- Q 1 X41.{ PHONE (7I3.) S70- 3266 <br /> OWNER'S ADDRESS 700 LOV fS ANA 14VS PdlI j T$C ? 2 00-L <br /> FACILITY CONTACT bLCNNIV 5 -"; L hre&4'ort- PHONE Q73- 6620 <br /> RESPONSIBLE PARTY(RP)DBA S'dN`C. A-S h4 fi A <br /> RPNAME L PHONE <br /> RP ADDRESS tt <br /> RPCONTACT a PHONE <br /> -NATURE -explosion, /dumInAmiateriat)-It O u Mf <br /> —4 pArl'+"" a1v1 1" w NAA;U1 !f4k,4 '+- 20 gcglfrj <br /> m»r Q 2 n,., 111t. 44m" r"6 w , / s l ib, <br /> TIME RECEIVED IS D TIME OF ARRIVAL — ' .TTIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> U►J At/AILtAt1Iz,, <br /> IDENTIFICATION OF MATERIAL I UM Pd k <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS WIQUID ❑ GRANULE <br /> REFERRALS TO r DATE MAILED <br /> DATE COMPLETED............PROP 65 b UAR ti 1,a <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> J N ICno•.r...l <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD,, COMPLETED? ❑ YES NO <br /> E.R BINDER COPIES: <br /> WHORT-TERM ON TOP C4NARRATIVE ❑ ANALYTICAL DATA [PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑REFERRALS ❑ MAP ❑ FILE CREATED <br /> EH22014rev 6/14/1999 <br />