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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> �.• ._,,�� •.oG Unit Supervisors <br /> Donna K.Heran,R.E.H.S. <br /> -" 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> vi Director Mike Huggins,R.E.H.S.,R.D.I. <br /> """ `'`' A101sen,R.E.H.S. Stockton, California 95202-2708 <br /> Douglas�V.Wilson,R.E.H.S. <br /> • �q. ��P Program Manager Telephone: (209) 468-3420 Mar,aret Lagorio,R.E.H.S. <br /> �i '6" Laurie A.Cotulla,R.E.H.S. Robert McClellon,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 <br /> Mark Barcellos,R.E.H.S. <br /> i/ EMERGENCY RESPONSE RECORD <br /> / <br /> DATE SHORT TERM# <br /> PREMIS ADDRESS DRESS/� P [ ,01 N . ktj f tr CITY s G �N <br /> DBA u 1V 1 G tom, I- NC.,4 - <br /> PREMISE OWNER U re 1'3�- edr P_ cc PHONE <br /> OWNER'S ADDRESS ,U : ,dD J (�l�,l-enl CA, <br /> FACILITY CONTACT P ev e1 6 e+� �'L� PHONE -/u C? <br /> RESPONSIBLE PARTY(RP)DBA u fjt' <br /> CUM <br /> RP NAME U N I PHONE <br /> RP ADDRESS N SP�►J W l M MA D! g$-7— <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) /���]v Av441__ <br /> TIME RECEIVED 2, TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDE IFICATION OF MATERIAL(CHENUc,u.rtmvowao) <br /> SUBSTANCE FORM ❑11 SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO V - DATE MAILED F 06&It— <br /> DATE COMPLETED............PROP 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 /> 9SHORT-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 /> 6/14/1999 <br /> EH22014rev <br />