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V <br /> ENVIRONMENTAL HEALTH .DEPARTMENT <br /> PpUIN SAN JOAQUIN COUNTY <br /> �o._ �.coG Unit Supervisors <br /> Donna K.Heran,R.E.H.S. Carl Bor an,R.E.H.S. <br /> A304 East Weber Avenue, Third Floor <br /> Director Mike Huggins,R.E.H.S.,R.D.I. <br /> Al Olsen,R.E.H.S. Stockton, California95202-2708 <br /> Douglas W.Wilson,R.E.H.S. <br /> • �Q. ��P Program Manager Telephone: (209)468-3420 Margaret Lagorio,R.E.H.S. <br /> F oR Laurie A.Cotulla,R.E.H.S. Robert McClellon,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 <br /> EMERGENCY RESPONSE RECORD Mark Barcellos,R.E.H.S. <br /> DATE I Tq t, SHORT TERM# C 00 O V $6 D <br /> PREMISEADDRESS <br /> l7 DD CITY �y • <br /> DBA / QD G /��D It 0L--ttA M S111;0 <br /> PREMISE OWNER S PHONE <br /> OWNER'S ADDRESS 2-7Z ZO <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DBA az."rz- <br /> RP NAME t k t^-n, PHONE <br /> RP ADDRESS G'✓ <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(ex los' ,spill,leak,fire,or abandoned/dumped material) <br /> a.,� . <br /> o�- <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE 7•pdP^' <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(06MCAL INVOLVED) d <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER G.A LIQUID ❑ GRANULE <br /> REFERRALS TO A111+ DATE MAILED <br /> DATE COMPLETED............PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> AAA <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 9MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> 6/14/1999 <br /> EH22014rev <br />