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San Joaquin County DIRECTOR <br /> O Environmental Health De artment Donna Heran, RENS <br /> p I`� ASSISTANT DIRECTOR <br /> r.Ff� y 600 East Main Street Laurie Cotulla,REHS <br /> Pl <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> •'': Carl Borgman,REHS <br /> n.:P Mike Huggins,RENS, RDE <br /> Cq� -o:R � Website: www.sjgov.org/ehd Margaret Lagorio,REHS <br /> Phone: (209)468-3420 Robert McClellon,REHS <br /> Fax: (209) 464-0138 Jeff Carruesco, REHS,RD) <br /> EMERGENCY RESPONSE RECORD <br /> Kasey Foley,REHS <br /> DATE: ( SHORT TERM#: Co O b 3 3C-f0--7 <br /> PREMISE ADDRESS: J . P 9 L t�T '-+ (R CITY: �D�C 1, - <br /> DBA: L.bn rl4% „�(Jj/L[�/�-� <br /> PREMISE OWNER: LIh ni tj N l Ctin&uL r -rt`�/�- PHONE: <br /> OWNER'S ADDRESS: <br /> FACILITY CONTACT: IVI f�'{!4 S �� ,f PHONE: - J <br /> RESPONSIBLE PARTY(RP)DBA: 1` <br /> RP NAME: !C- LALzA A, gyp- �j n y PHONE: 6 1� C) <br /> RP ADDRESS: " o i 0 r� ��' 'ul -{ <br /> RP CONTACT: .Z,. PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> Sir..._ _ LL% / 0G pit <br /> TIME RECEIVED: TIME OF ARRIVAL: Z TIME OF DEPARTURE: ZL'16a. <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL icHEMcni.WvoLvEo> w 4vryl, <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER '5�J GAS ❑ LIQUID ❑GRANULE <br /> REFERRALS TO: DATE MAILED: <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 /> 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 /> Document[ Page: !of 3 6/14/[999 <br />