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ENVIRONMENTAL HEALTH DEPARTMENT <br /> oPQu�ry <br /> SAN JOAQUIN COUNTY <br /> 4 � Donna K.Heran,R.E.H.S. UnitSuperuisors <br /> Director 304 East Weber Avenue,Third Floor . Carl Borgman,R E.H.S. <br /> j Al Olsen,R.E.H.S. Stockton, California 95202-2708 Mice Huggins,R.E.H.S.,R.D.I. <br /> • Program Manager Douglas W.Wilson,R.E.H.S. <br /> q<'r Laurie A.Cotulla,R.E.H.S. Telephone: (209)468-3420 Margaret Lagorio,R.E.H.S', <br /> Program Manager Fax: (209)464-0138 Robcrt McClellon`R.E:H.S.." <br /> EMERGENCY RESPONSE RECORD Mark Barcellos,R.E.H.S. <br /> DATE _!Z �` p SHORT TERM# <br /> PREMISE ADDRESS-,,. "Db Rw-1 17— CITY <br /> LODI <br /> DBA ..__,_M,JO-K PPAC-4 VA Ag j f 4 f ll <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS , <br /> FACILITY CONTACT.GrYQO PHONE Zf� — /0 rL 1 <br /> RESPONSIBLE PARTY(RP)DBA Aja?' Zn <br /> RP NAME i PHONE. <br /> RP ADDRESS ' <br /> RP CONTACT r PHONE <br /> NATURE OF COMPLAINT(explosion,'spill,leak,fire,or abandoned/dumped material) <br /> c� L(�YtA�iatn/►�! <br /> . S <br /> i <br /> TIME RI;CEIV$I) 1 TIME OF ARRIVAL •d?7 ro► TIME OF DEPARTURE Lj-.I S <br /> PERSONS AT SCENE i <br /> NAME AGENCY _ <br /> •^ 'y�, PHONE TOA TOD <br /> ttc <br /> A <br /> t � <br /> t <br /> IDENTIFICATION OF MATERIAL MfWtC.ALDW0LVEa) p( - <br /> SUBSTANCE FORM ❑SOLID ❑POWDER ® GAS WLIQUID Cf GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65; _ UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ;w ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑YES ❑NO <br /> F:.R.BINDER COPIES: <br /> ©SHORT-TERM ON TOP ❑NARRATIVE ❑ANALYTICAL DATA 0 PROP 65/UAR <br /> ❑EXPOSURE RECORD 0 MANIFEST ® CLEAN UP REPORT 0 OTHER AGENCY REPORTS l <br /> ❑REFERRALS ❑ MAP ❑FILE CREATED ! <br /> EH22014rev 6/14/1999 <br />