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ENVIRONMENTAL HEALTH DEPARTMENT <br /> PQ u I�y I <br /> SAN JOAQUIN COUNTY <br /> =" Unit Supervisors <br /> Donna K.Heran,R.E.H.S. P <br /> Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S-,R.D.I. <br /> Program Manager Douglas W.Wilson,R.E.H.S. i <br /> 4�lFo"Ra g Telephone: (209) 468-3420 Mar La or <br /> Laurie A.Cotulla,R.E.H.S. Margaret io,R.E.H.S. <br /> g ; <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD Mark Barcellos,R.E.H.S. ' <br /> DATE 10 8 6 SHORT TERM# COO 6 2. 52-7-7 <br /> PREMISE ADDRESS. CITY fo<, IGka 06J <br /> DBA Z A c,K 2 n�• L�, _So/g 7 <br /> PREMISE OWNER r PHONE <br /> OWNER'S ADDRESS . O G DF reS NdAti 93:7-7 g <br /> FACILITY CONTACT <br /> Lev" A2h <br /> LA PA pRDC PHONE e)-k ZIYL <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME <br /> PHONE <br /> RP ADDRESS <br /> RPCONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> A �nntrNEAV— <br /> TIME RECEIVED 04P-! TIME OF ARRIVAL - . 10 JO TIME OF DEPARTURE-- S <br /> II PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Bob , elm+ MSN S4DI✓ >< i~1 Pim be �. 6 PI- 22 G1 — -- <br /> T eo vAn L9n�n 2 4�t[�-1 'q�-►''� t Glut - 612 9 <br /> IDENTIFICATION OF MATERIAL(mEwcALINvoLvED) A bN g <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER =GAS ❑ LIQUID ❑ GRANULE <br /> REFERRALS TO V A - P, C - jb DATE <br /> i <br /> DATE COMPLETED............PROP 65 1610 hit. UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES JFNO <br /> E.R.BINDER COPIES: <br /> 'SHORT-TERM ON TOP ZI NARRATIVE ❑ ANALYTICAL DATA XPROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS 1.MAP ❑ FILE CREATED <br /> EH22014rev 6/14/1999 <br /> .. . l <br />