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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOA COUNTY Unit Supervisors <br /> Donna K.Heran R.E.H.S. Third Floor Carl Boins,R. R.E.H.S. <br /> 304 East Weber Avenue, Mike Huggins,R.E.H.S.,R.D.I. <br /> Director <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Douglas W.Wilson,R1.1-I.S. <br /> Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> QtS. <br /> i'Fi Laurie A.Cotulla,R.E.H.S. Fax: (209) 464-0138 Robert M rcell s, ,E.H. . <br /> Program Manager Mark Barceilos,R.E.H.S. <br /> 1EMERGENCY RESPONSE RECORDCo �20�3 <br /> DATE Z Z b SHORT TERM# O j I f <br /> PREMISE ADDRESS oyj' �� • CITY T <br /> DSA i e f 54 - f SLq,0 A TK,C&- <br /> PREMISE OWNER ehL, 13 Al,5bbW\ PHONEX - 41`'l� 7sJ <br /> OWNER'S ADDRESS �R <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DBA <br /> PHONE <br /> RP NAME <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandonedidumped material) <br /> TIME RECEIVED (?{, TIME OF ARRIVAL 10 t Ll TIME OF DEPARTURE M <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> \N wS K-I S. e� 5 1 Qf 24 ,KSS <br /> IDENTIFICATION OF MATERIAL iCKEWCAimVOLVED) N <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER 1:1 GAS IQUID ElGRANrrULE <br /> REFERRALS TO ¢ L ' 1 k �`' DATE MAILED b � <br /> DATE COMPLETED 65 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 13 CLEAN UP REPORT OTHER AGENCY REPORTS <br /> �REFERRALS MAP ❑ FILE CREATED <br /> 6/14/1999 <br /> EH22014rev <br />