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San Joaquin County DIRECTOR <br /> Donna Heran, REHS <br /> oP IV .� Environmental Health Department <br /> I' ASSISTANT DIRECTOR <br /> 600 East Main Street Laurie Cotulla,REHS <br /> Stockton, California 95202-3029 <br /> _ PROGRAM COORDINATORS <br /> Carl Borgman,REHS <br /> c.. p Mike Huggins, REHS, RDI <br /> Rte` Website: www sjgov.org/ehd 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: Lma, —2.oM SHORT TERM#: qC De�tt 00 3 D 75(p <br /> PREMISE ADDRESS: ?�33 k CITY: I�CX�t <br /> DBA: 17 <br /> PREMISE OWNER: PHONE: ` <br /> OWNER'S ADDRESS: <br /> FACILITY CONTACT: L PHONE: <br /> RESPONSIBLE PARTY(RP)DBA:_ �'� Ti() <br /> RP NAME: PHONE: <br /> RP ADDRESS: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion,spill, leak, fire, or abandoned/dumped material) <br /> A WlAiLL ; Aja c_ WaL FQfkS4M iD noc <br /> TIME RECEIVED: TIME OF ARRIVAL: L(n V✓( TIME OF DEPARTURE: ( M <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> sa-�• C�Pir� C� �...1✓vra �Ra�=1 (�a� v��6�15`l <br /> IDENTIFICATION OF MATERIAL ccIucu.wvoLVEn <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 NO <br /> V.BINDER COPIES: +i <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 /> Documentl Page: l of3 6/14/1999 <br />