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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> �. _ .�'•oG Unit Supervisors <br /> Donna K.Heran,R.E.H.S. Carl Borgman,R.E.H.S. <br /> ?�'� "� A Director 304 East Weber Avenue, Third Floor <br /> N: <br /> Y s Mike Huggins,R.E.H.S.,R.D.I. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Douglas W.Wilson,R.E.H.S. <br /> r.. - Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> q��FO.R�j <br /> Laurie A.Cotulla,R.E.H.S. Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager Mark Barcellos,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD ? <br /> DATE 1 ` Z 610 3 SHORT TERM# C7p��Z J <br /> PREMISE ADDRESS 1 SO TALK -riDNr /Zo. CITY l� f�dt-i <br /> DBA 1 0^ ILVV to(4 7-4 <br /> PREMISE OWNER �i PHONE SaI�l �lI <br /> OWNERS ADDRESS 41 �D� S• �r,4JmJ c�( �j ZO 1 �5(��"� (�� (4b3 <br /> FACILITY CONTACT -3-1,hal�N��- /7 PHONE G t" <br /> RESPONSIBLE PARTY(RP)DBA Seu VV wai l L�41�'� ���S =So <br /> o -AA wei <br /> RP NAME C kr L pppd Se&K PHONE ?N) — <br /> RP ADDRESS (� DrO401110 WA�71 A405 AZ IM ly <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> 210 <br /> A In <br /> TIME RECEIVED T ,[6 4 TIME OF ARRIVAL -1 i 4 TIME OF DEPARTURE -2,(0(2 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDEnOF CATIONEN0cuMvoweo) GAS <br /> SUBSTANCE FORM ❑SOLID [I POWDER C1 LIQUID ❑ GRANULE <br /> DATE MAILED <br /> REFERRALS TO <br /> DATE COMPLETED............PROP 65 6 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> 0 REFERRALS ❑ MAP ❑ FILE CREATED <br />