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ENVIR4A4ENTAL HEALTHtEPARTMENT <br /> z°A' �4, 15 SAN JOAQUIN COUNTY <br /> 2 Unit Su <br /> y <br /> N• � :.! Donna K.Haran,R.E.H.S. Supervisors " <br /> Director 344 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> . Al Olsen,R.E.H.S. Stockton, California 95242-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> Program Manager Douglas W.Wilson,R.E.H.S. <br /> l! ° � Laurie A.Cotulla,R.E.H.S. <br /> Telephone: (249) 468-3424 Margaret Lagorio,R.E.H.S. <' <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.Se <br /> II EMERGENCY RESPONSE RECORD Mark Barcellos,R.E.H.S. <br /> DATE 14 0 b SHORT TERM# C0052- 5'2-7--7 <br /> PREMISE ADDRESS ! l I NAV 1 , CITY <br /> DBA —2 �. 1? <br /> PREMISE OWNER �^ PHONE <br /> OWNER'S ADDRESS r Q d ( Z ��Cj 7 [`¢S f•,1d (�Ay g <br /> FACILITY CONTACT Leo N A 2 b I Q tA 2_ — PHONE <br /> RESPONSIBLE PARTY(RP)DBA <br /> 'RP NAME _ PHONE - <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,Ere,or abandoned/dumped material) <br /> TIME RECEIVED , r TIME OF ARRIVAL r r <br /> • I U TIME OF DEPARTURE <br /> PERSONS AT SCENE �— <br /> NAME AGENCY PHONE TOA TOD <br /> Bob New MSN s � Kf► � 63'7- 224 <br /> Ln eo u L n^ 2 4-r r9-rrvv Cjq — b 121 <br /> IDENTIFICATION OF MATERIAL(aimacA,iNvowiu)) _ lel m M oN } q <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER XGAS ❑ LIQUID ❑ GF <br /> ANULE <br /> REFERRALS TO �. !V . - .�, DATE orl¢� <br /> DATE COMPLETED............PROP 65 UAR <br /> PERSONS EXPOSED and/or INRJRED <br /> NAME ADDRESS PHONE <br /> goo <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD,, COMPLETED? ❑ YES NO <br /> E.R.BINDER COPIES: <br /> `SHORT-TERM ON TOP V NARRATIVE ❑ ANALYTICAL DATA PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS X MAP ❑ FILE CREATED <br /> EH22014rev <br /> 6/14/1999 <br />