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` I <br /> R C , <br /> ENVIRONMENTAL HEALTH DERkit4iNT <br /> u.! :•.r SAN J OAQ v I ' COUNTY Unit Supervisors <br /> Carl Borgman,R.E.H.S. <br /> Donna K.Heran,R.E.H.S• 304 East Weber Avenue,Third Floor Mike Huggins,R.E.H.S.,R.D.1- <br /> Direcmr Douglas W.Nilson,R.E.H.S. <br /> At Olsen,R.£.H.s. Stockton, California 95202-27 <br /> 1 p'. Progran,Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E_H.S. <br /> ., Robert McClellon,R.E.H.S. <br /> z Laurie A.Cotulla,R.E.H.S. _ Fax. (209) 464-0138 Mark Barce'llos,R.E.H.S. <br /> Program Manager <br /> EMERGE19CX RESPONSE RECORD <br /> SHORT TERM# <br /> DATE CITY <br /> PREMISSE DRESS <br /> DBA-Sy`� PHONE <br /> PREMISE OWNER 2- <br /> OWNER'S ADDRESS PHONE <br /> FACILITY CONTACT <br /> RESPONSIBLE PARTY(RP)DBA PHONE <br /> RP NAME <br /> RP ADDRESS PHONE <br /> RP CONTACT <br /> NATURE OF COMPLAINT(explosion,spill,leak,firms ora aadoned/dumped material) <br /> �.�S.ti�-- TIME OF DEPARTURE :5- — <br /> TIME RECEIVED TIME OF ARRIVAL S <br /> PERSONS AT SCENE PHONE TOA TOD <br /> NAME <br /> AGENCY <br /> IDENTIFICATION OF MATERIAL tcHnuc- VOW.ED, AS ❑ LIQUID ❑ GRANULE <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER DATE MAILED <br /> REFERRALS TO UAR <br /> DATE COMPLETED............PROP b5 <br /> PERSONS EXPOSED and/or INJURED PHONE <br /> NAME ADDRESS <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑YES <br /> ❑NO <br /> E.R.BINDER C PIE M! IARRATIVE ❑ANALYTICAL DATA 'ZROP 651 UAR <br /> r4nH RT-TERM ON TOP ❑OTHER AGENCY REPORT <br /> ❑EXPOSURE RECORD 0 MAP FEST ❑FILE <br /> CREATED DORT <br /> 0 REFERRALS ❑MAP <br />