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4 <br /> i <br /> San Joaquin County DIRECTOR <br /> PQ N Donna Heran, REHS <br /> Environmental Health Department <br /> O ASSISTANT DIRECTOR <br /> S00 Eas#Main Street Laurie-Cotulla,REHS <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> 1.11iL7 <br /> ' j. Carl Borgman,REHS <br /> Mike Huggins,REHS, RDl <br /> q i fi o a � Website: www.S/gov.org1ehd Margaret Lagorio, REHS <br /> Phone: (209)468-3420 Robert McClellon, REHS <br /> Fax: (209)464-0138 .teff Carruesco,REHS, RDI <br /> EMERGENCY RESPONSE RECORD Kasey Foley,REHS <br /> DATE: � � p n SHORT TERM#- c o o o'3 O <br /> PREMISE ADDRESS: �c�d S°`1.1i, i-k o-n X164 T ,g 1 rrY: :CQ L 0 <br /> DBA: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: L,III Kf if hPY1 <br /> RP NAME: PHONE: <br /> RP ADDRESS: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> Y-Aa.L 4u mv i`n� c r��C!Q2►± of W.L ak' off`- On � <br /> TIME RECEIVED: TIME OF ARRIVAL: 24 -�Nti TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME �AGENCY PHONE TOA TOD <br /> f`�t b <br /> IDENTIFICATION OF MATERIAL(CHFMCAL WVOLVED) Ai�p 96a,41 wdo'e' ` 1 Qm!� V L <br /> SUBSTANCE FORM SOLID POWDER GAS LIQUID WGRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED........PROP 55: Pb-q- UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES aNO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA PROP b5/UAR <br /> EXPOSURE RECORD MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> Documents Page: l of 611411999 <br />