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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> rs <br /> Donna K.Heran,R.E.H.S. l Borgu an,R.o. <br /> Director <br /> 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.s. <br /> AI Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.1. <br /> Douglas W.Wilson,R.E.H.S. <br /> Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> r o R Laurie A.Cotulla,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Mark Barcelios,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD <br /> DATE '{A 4 SHORT TERM# <br /> PREMISE` ESS � 11,0 CITY 1 T� <br /> DBA W1V <br /> PREMISE OWNER �N t w,>( S PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT fA%eUtS QM110 DOV PHONE (.jj0g)% _ 14 <br /> RESPONSIBLE PARTY(RP)DBA c ! <br /> RP NAME PHONE(un !; ptQIp <br /> RP ADDRES5 e. G <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> 9 - a AaNvis 6 L r o mice <br /> TIME RECEIVED 1�-�Yt kVO TIME OF ARRIVAL �� �� TIME OF DEPARTURE <br /> vw <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 1 a '✓ WI S a <br /> 0 <br /> cdwal ti. rAw 4\ <br /> i <br /> IDENTIFICATION OF MATERIAL(CHFMCa.,"WOLVED) �iQSQ <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> I <br /> ".PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E.R.HINDER COPIES. <br /> ❑ SHORT-TERM ON TOP 0-NARRATIVE ANALYTICAL DATA '�d PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS . <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> I <br /> EH22014rev 6/14/1999 <br />