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Environmental Health Department <br />600 <br />DIRECTOR <br />Donna Heran, REHS <br />ASSISTANT DIRECTOR <br />Laurie Cotulla, REHS <br />�wMarPROGRAM COORDINATORS <br />garet <br />Carl Borgman, REHS <br />Website; www.Sjgov.Org/ehd Mike Huggins, RENS, RDI <br />468-3420 Lagorio, RENS <br />Phone: 209 <br />• ( Robert McClellon, REHS <br />Fax: (209) 464-0138 Jeff Carruesco, REHS, RDI <br />(� EMERGENCY RESPONSE RECORD Kasey(Folley,, REHS <br />DATE: i` SHORT TERM 1t: c V 00 W t <br />PREMISEiiADDRESS:_ Z L S" i'[�/t. ��-c CITY: fi G&L/ <br />DBA: �'tffL� �L-w= w -A f e i•°/R�- F�Nli � �'T <br />PREMISE OWNER: PHONE: <br />OWNER'S <br />G <br />FACILITY CONTACT: ge -cwj d -V .L PHONE: 1`" E <br />RESPONSIBLE PARTY (RP) DBA: P* I A1CI G T f f� 2coli 7 . <br />RP ADDRESS:_ 37 Wehe-in <br />RP W <br />NATURE OF COMPLAINT <br />IM <br />spill, leak, fire, or abandoned/dumped material) <br />PHONE: <br />NVI <br />TIME RECEIVED: -V ! A TIME OF ARRIVAL: 9 1S -01A TIME OF DEPARTURE: /Q • a <br />PERSONS AT SCENE f <br />NAME AGENCY PHONE TOA TOD <br />Iva `g' a- P% /ic . Sof r F16. ,,x" !t -. 9 1 .— 9 F 19,0. <br />&� o.h 14rFI1P v C_.nS.A&6• 4G'?? - 97Z40 l4) -fojJ 7. <br />IDENTIFICATION OF MATERIAL tcmgcwt wvoLvaw & Ago C f rVZ-- <br />SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID []GRANULE <br />REFERRALS <br />DATE COMPLETED ........PROP 65: <br />PERSONS EXPOSED and/or INJURED <br />U, <br />150114:r <br />NAME ADDRESS PHONE <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES NO <br />E. R. BINDER COPIES: <br />SHORT-TERM ON TOP <br />EXPOSURE RECORD <br />❑ REFERRALS <br />NARRATIVE ❑ ANALYTICAL DATA <br />MANIFEST ❑ CLEAN UP REPORT <br />MAP ® FILE CREATED <br />PROP 65 / UAR <br />OTHER AGENCY REPORTS <br />Documend Page, 1 of 3 6/14/1999 <br />