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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> - Unfit Supervisors <br /> a—� Donna K.Heran,R.E.H.S. <br /> �I304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Director na <br /> 1 F � Mike Huins,R.E.H.S_R.D.I. <br /> �• —•--r ,e.'• Al Olsen,R.E.H.S. Stockton, California- 95202-2708 Douglas W.Wilson,R.E.H.S. <br /> Pro;rain hfanager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.Catulla,R.E.H.S. Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager tMark Barcellos,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD �} <br /> DATE 1 Z-2-1 -C)3 SHORTTERM# C0000O1 1 <br /> PREMISEADDRESS 1275 15 Mac-Y-) Sf (kDad `SidLwQL`-) CITY <br /> r� <br /> DBA <br /> PREMISE OWNER D� T 17CLr�fC CCv PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DSA RM WOM em. ✓C. Fv(xI 8a qk, <br /> RP NAME W VYIrh'L. PHONE 7D7. 5 Z3 • -79 00 <br /> RP ADDRESS 332D c us-fr!'a DYl✓e". c�(�► �"�L� <br /> RP CONTACT DM PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) f <br /> OY)s e&Cf cS ! 1 ed 47111 YD OA LV Gi.F'Lu <br /> _ d i sed f ink Y-M d r r7 <br /> " c <br /> c <br /> TIME RECEIVED ��• TIME OF ARRIVAL 12. 3D TIME OF DEPARTURE 2• -3 0 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD U <br /> 11'1� .D 3Ll ILK <br /> Ire 'f82. 11 :33 <br /> MiI<.c- C,roU .L�. <br /> �'-w• 2-34 - FY-S 01, °o(a 4 I.AL <br /> ^~ <br /> #1-) 7 G�.1P.►� Z3`F SDI `C;+try .� <br /> IDENTIFICATION OF MATERIAL(cmvac,zrnvoe%Eo SC <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TODATE MAILED <br /> DATE COMPLETED............PROP 65 !z'.2 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL rOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> i:.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 /> 6/14/1999 <br /> EH22014rev <br />