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L' <br /> - ENVIRONMENTAL HEALTH DEPARTMENT <br /> OG <br /> Donna K.Reran,R.E.H.S. SAN JOAQUIN COUNTYUnit Supervisors . <br /> Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> 1rMike Huggins,R.E.H.S.,R.D.I. <br /> Al Olsen,R.E.H.S. tOCICtOn, California 95202-2708 Douglas W.Wilson,R.E.H.S. <br /> a4 � a Program Manager Tele hone: 209 468-3420 Margaret La orio,R.E.H.S. <br /> Laurie A.Cotulla,R.E.H.S. { g g <br /> Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager Mark Bareellos,R.E.H.S. <br /> n. EMERGENCY RESPONSE RECORD <br /> DATE V U SHORT TERM# <br /> PREMISE ADDRESS �. �' �.�� ,� + CITY %t A ' <br /> DBA GCS <br /> PREMISE OWNE fV PHONE <br /> OWNER'S ADDRESS adf n <br /> FACILITY CONTACT W PHONE �� d <br /> RESPONSIBLE PARTY(RP)DBA 64VIIS V 1 <br /> RP NAME PHONE <br /> .r <br /> RP ADDRESS <br /> RP CONTACT _ �` PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> � 1f <br /> TIME RECEIVED TIME OF ARRIVAL Ia 170 �M TIME OF DEPARTURE 11160 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> wV1 Ove" <br /> � whtvk [ <br /> GAW <br /> V ClAqT%it <br /> IDENTIFICATION OF MATE AL,.cu.irrvo� Qfi h i <br /> SUBSTANCE FORM SOLID BlI 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 /> eV12 <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 /> ❑ REFERRALS ❑ MAP ❑ FILE CREATED <br /> EH22014rev 6/14/1999 <br />