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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Unit Supervisors <br /> Donna K.Heran,R.E.H.S. 304 East Weber Avenue Third Floor g <br /> Carl Bor man,R.E.H.S. <br /> Director Mike Huggins,R.E.H.S.,R.B.I. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Douglas W.Wilson,R.E.H.S. <br /> cR�iFo'ua`PProgram Manager Telephone: (209) 468-3420 Margaret Lagorio,R.F.H.S. <br /> Laurie A.Cotulla,R.E.H.S. Robert McClellon,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Mark Barcellos,R.E.H.S. <br /> J EMERGENCY RESPONSE RECORD <br /> DATE t 2 l �y SHORT TERM# BD L2 <br /> A4-e <br /> S�2 <br /> PREMISE ADDRESS J D S VAI. �!� 1`C� �'e-< CITY A4 4 PJ 4 e L <br /> DBA ` f o Lel Dn 1� <br /> *RR*Sla OWNER '{' P44-r1 C1 A U m M PHOONE - <br /> OWNER'S ADDRESS �q � j F• �Od�h �9�*� � ��'N -g ��J�L <br /> FACILI'T'Y CONTACT (�f e� CI PHONE p �� 6�! eek <br /> RESPONSIBLE PARTY(RP)DBA V <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> Cry ase 1 f,.v Ate, urs e--j <br /> TIME RECEIVED �[.3 TIME OF ARRIVAL Y• 3O p 01 _ TIME OF DEPARTURE 6,26jF^-% <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> a'A Nn!�:j " j Ad an a 1Cfrc. 02 bob- syw-y r --- 6 ;�S , <br /> n � La PoWc, word ..-_ $21-1- 6 : <br /> IDENTIFICATION OF MATERIAL(caEwcALurvo,-ven o <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS IQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> a f NAME ADDRESS PHONE <br /> N <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES ❑ NO <br /> E.R.BINDER COPIES. <br /> )irSHORT-TERM ON TOP ISZNARRATIVE ❑ ANALYTICAL DATA ,PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS EMAP ❑ FILE CREATED <br /> EH22014rev 6/14/1999 <br />