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u, ENVIRONMENTAL HEALTH DEPARTMENT <br /> Pou�N SAN JOAQUIN COUNTY <br /> Q ` Donna K.Heran,R.E.H.S. Unit Supervisors <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. <br /> aC] "oRa La ori , <br /> Laurie A.Cotulla,R.E.H.S. Telephone: (209) 468-3420 Margaret g o R.E.H.S., <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Mark Barcellos,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD <br /> DATE --jkf7,PtI SHORT TERM# 12 <br /> PREMISE ADDRESS ���` ,0 22 � 4CLC CITY S �J <br /> DBA _�� �y e•+lrs c7F'Yo i:[-✓� USrLG <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS Idl R-0 <br /> FACILITY CONTACT PVj PHONE 70-7 'j( '$r <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> J �, 1 <br /> i <br /> TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE ' <br /> NAME AGENCY PHONE TOA TOD 1 <br /> 1 <br /> f <br /> IDENTIFICATION OF MATERIAL t01E�UcuwvoLven7 <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS O'LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 UAR <br /> PERSONS EXPOSED and/or 1NRJRED <br /> NAME ADDRESS PHONE J <br /> J <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? El 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 /> EH22014rev <br /> 6/14/1999 <br />