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ENVIROENTAL HEALTA)EPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Supervisors <br /> Su <br /> Q• ,;. - , ; ?.� Donna K.Heran,R.E.H.S. UnP <br /> 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Director <br /> Mike Huggins,R.E.H.S.,R.D.I. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Douglas W.Wilson,R.E.H.S. <br /> • C`q C'F O R.��P • Program Manager Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.og Manager Co R.E.H.S. <br /> Program ManFax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Mark Barcellos,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD <br /> DATE 1123 /0-77 SHORT TERM# C D 062- S7 67 <br /> PREMISE ADDRESS M IC in IQ 'SN Q US l (-14Z- CITY -V-0&(G><a7%1 <br /> DBA <br /> PREMISE OWNER Q tJ�0A1 4/ Z (- PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT d PHONE <br /> RESPONSIBLE PARTY(RP)DBA M41, A N wQg� -fSDN1 7/-u&k-Ins <br /> RP NAME /V l Q IV(J AF[, tl!D/ }aZ, PHONE Z - <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> .�! ���yi 6C�C�r�r1 ,�r►1 A UQ(n ftp- A-Gc.1�oti�— i n ��!�<�� <br /> TIME RECEIVED It ! Z`S:.A. TIME OF ARRIVAL 2 d Y M TIME OF DEPARTURE­? <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Q�ar 4- Gy 41- e u to = <br /> e l ck 6"-z w i C P — <br /> Nvw.&VA V P IM Pq-r60AQc r <br /> Me,i)�A 4o , 3 , 16, <br /> T N IZ- <br /> ^^-- <br /> IDENTIFICATION OF MATERIAL(cinflMMV0LVM) ',Q �- "F 4,&j�-i oCeeyK. <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 2 Lf To 5 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> r NAME ADDRESS PHONE <br /> NI <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA ROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> EH22014rev 6/14/1999 <br />