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r' <br /> San Joaquin County DIRECTOR <br /> Donna Heran, REHS <br /> Environmental Health Department <br /> OG I ASSISTANT DIRECTOR <br /> r. 600 East Main Street Laurie Cotulla,REHS <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> r <br /> Car!Borgman, REHS <br /> Website: www.s ov.or /ehd Mike Huggins, REHS, RDI <br /> Lri=0R� �g g Margaret Lagodo,REHS <br /> Phone: (209) 468-3420 Robert McClellon, REHS <br /> Fax: (209)464.0138 .teff Carruesco, REHS, RD] <br /> EMERGENCY RESPONSE RECORD Kasey Foley, REHS <br /> /n� <br /> DATE:= ], J-Z�aG _ SHORT TERM#: C.:.D Ob 3 0 7�� <br /> PREMISE ADDRESS: 3� I`�•_ W/ItrS�E�O� , .,. CITY: <br /> DBA: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: <br /> FACILITY CONTACT: PHONE: <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 /> TIME RECEIVED: �ZD M TIME OF ARRIVAL: (D IA TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> - Cid- f 36 i511� JLS <br /> Se <br /> IDENTIFICATION OF MATERIAL(CHEWCAL IWOLVEn <br /> SUBSTANCE FORM (—]SOLID ❑ POWDER ❑ 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 r7NO <br /> X.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA PROP 65/UAR <br /> EXPOSURE RECORD MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> f-1REFERRALSMAP ❑ FILE CREATED <br /> Documentl Page: l of 6/14/1999 <br />