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ENVIRONMENTAL HEALTH DEPARTMENT <br /> °P1-1 N c SAN JOAQUIN COUNTY <br /> ).• _ fit G <br /> Z` ,°� ?, Donna K.Heran,R.E.H.S. Unit Supervisors <br /> AAE ` 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 /> ��c " Program Manager Telephone: 209 468-3420 Douglas W.Wilson,R.E.H.S. <br /> F o a Laurie A.Cotulla,R.E.H.S. p ( ) Margaret Lagorio,R.E.H.S. <br /> Program Manager Fax: (209)464-0138 Robert McClellon,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD Mark <br /> gBarcellos,R.E.H.S. <br /> DATE L U 6 SHORT TERM# 000 Z S 1 <br /> PREMISE ADDRESS 1000 6-31� CITY t.i opo 712-7 <br /> DBA <br /> PREMISE OWNER �� PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT 1��,io„--, � PHONq ke'Z— <br /> RESPONSIBLE PARTY(RP)DBA__ <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT ��Q PHONE <br /> NATURE OF COMPLA T(explosion,spill,leak,fire,or abandoned/dumped material <br /> . 2- t, <br /> Q <br /> Q <br /> e <br /> TIME RECEIVED ,6• YOA A\. TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> IDENTIFICATION OF MATERIAL(06MCA INVOLven) C <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 Qgb — 0 b- 0-ZUAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> NIA- <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑YES ❑ NO <br /> R.BINDER COPIES: <br /> SHORT-TERM ON TOP XNARRATIVE ❑ ANALYTICAL DATA PROP 65/UAR <br /> ❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑ REFERRALS gMAP ❑ FILE CREATED <br /> EH22014rev 6/14/1999 <br />