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d` <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna K.Heran,R.E.H.S. Unit Supervisors <br /> Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Al Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> "`P • Manager ram M <br /> Pro Douglas W.Wilson,R.E.H.S. <br /> 8 g Telephone: 209 468-3420 Margaret La orio,R.E.H.S. <br /> Man <br /> Program Manager FOR Laurie A.Co R.E.H.S. Fax: (2 9) 464-0138 Robert McCl lion,R.E.H.S. <br /> Mark Barcellos,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD <br /> DATE �� J C�V SHORT TERM# S <br /> PREMISE ADDRESS 1_"76C) W- W A(aIA< CITY <br /> DBA _ A 2 L v J!" <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT M l A;. P X Q�r!/"1 PHONE <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,s ill,leak,fire,or abandoned/dumped material) <br /> �. r c v QA r r <br /> AAIA4 1 rn IL. <br /> TIME RECEIVED H D�''�'1 TIME OF ARRIVAL ( TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> -r n�4 -4AOi RIO 141-bO --,fir — <br /> IDENTIFICATION OF MATERIAL(cHeacu INVOLVED) <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 Z UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> N I Dr <br /> 1 <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES NO <br /> E.R.BINDER COPIES: <br /> RSHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA kPROP 65/UAR <br /> EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS MAP ❑ FILE CREATED <br /> EH22014rev 6/14/1999 <br />