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f <br /> ENVIRONMENTAL HEALTH DEPARTMENT, <br /> SAN JOA UIN COUNTY Unit Supervisors:A• . . � <br /> Donna I-Heran,R.E.H,S. Carl Borgman,R.E.H.S. <br /> f ''r Director 304 East Weber Avenue,Third Floor Mike Huggins,R.E.H.S.,R.D.I. <br /> Al dlsen,R.E.H S. Stockton,California 95202-2708 Douglas W,Wilson,R.E.H.S. <br /> w'• Program ManagerTelephone: (209)468-3424 Margaret Lagorio,R.E.H.S. <br /> de A.Cotnlla,RJE.H.S. Robert McClellon,R.E.H.S. <br /> LauFax: (209)464-0138 Mark Barcellos,R.E.H.S. <br /> Program Manager <br /> EM Z RGENCY RESPONSE RECORD <br /> DATE • 0-1 . _ SHORT TERM# <br /> PREMISE ADDRESS 7'1 CITY -- <br /> DBA <br /> PREMISE OWNER �Im lot PHONE <br /> OWNER'S ADDRESS D � 2 Q f SS370 <br /> PHONE <br /> FACILI7`Y CONTACT <br /> RESPONSIBLE PARTY(RP)DBA <br /> PHONE <br /> RP NAME <br /> RP ADDRESS <br /> • PHONE <br /> RP CONTACT <br /> N OF COMPLAINT(exPlosron,spill,leak,fire,or aban onedldu material) <br /> TIME RECEIVED <br /> TIME OF ARRIVAL � M TIME OF DEPARTURE,�•��� <br /> PERSONS AT SCENE GEN PILO+ATF � TOD <br /> ow <br /> .UJ l kS� <br /> IDE MFICA71ON OF MATERIAL(cH—m"L-m �B... 70P f G Q G <br /> SUBSTANCE FORM D SOLID D POWDER D GAS LIQUID ❑'GRANULE <br /> DATE MAILED <br /> REFERRALS TO UAR <br /> DATE COMPLETED............PROP 65 ' <br /> PERSONS EXPOSED and/or INJURED NONE <br /> I� r ADI} <br /> lI[�► i- �'r ' <br /> 'PERSONAL TOxICSUBSTANC. EXPOSURE RECORD" COMPLETED? D YES D NO <br /> ❑ANALYTICAL DATA 0 PROP 651 uAR <br /> RT-TERM ON TOP �NARRATIVE <br /> A!�BINDE�R <br /> fiXPOSUkE RECORD D MMAANIFEST Cl CLEAN UP D FILE CREARE PORT ❑(7fHER AGENCY REPORTS <br /> D REFERRALS <br /> 6/14/1999 <br /> SH224Y4rev <br />