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San Joaquin County DIRECTOR <br /> Donna Heran,REHS <br /> = Environmental Health Department <br /> ASSISTANT DIRECTOR <br /> 600 East Main Street Laurie Cotulla,REHS <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> Carl Borgman,REHS <br /> Mike Hu <br /> C'•:",; ggins,REHS,RDi <br /> 4�l;Fo•p Website: uvww.s�gov.org/ehd Margaret Lagorio,REHS <br /> Phone: (209)468-3420 Robert McClellon, REHS <br /> Fax: (209)464.0138 Jeff Carruesco,REHS,Rol <br /> EMERGENCY RESPONSE RECORD Kasey Foley,REHS <br /> DATE: CJ SHORT TERM#: <br /> PREMISE ADDRESS: �'1" CITY: <br /> DBA: : <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: ,+! �! py <br /> FACILITY CONTACT: `�I .� t)wc—PHONE: C q 1 / <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: PHONE: <br /> RP ADDRESS: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/durnped material) L <br /> Q C ON P? 'T <br /> TIME RECEIVED: r nM TIME OF ARRIVAL: r I d TIME OF DEPARTURE: 2Z C--(%l9 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL xmEwcAL wvor vaoi <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID []GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED........PROP 65: A UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> IJ\J <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD COMPLETED? ❑ YES O <br /> E.R,BINDER COPIES: 1� <br /> I SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA f51J PROP 65/UAR <br /> EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> Ckxurnentl Page: t of 6/W1499 <br />