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ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q <br /> SAN JOAUIN COUNTY <br /> Unit Supervisors <br /> Donna K.Heran,R.E.H.S. Carl Bor man,R.E.H.S. <br /> 304 East Weber Avenue, Third Floor Borg <br /> man, <br /> Mike Huggins,R.E.H.S.,R.D.I. <br /> • AlOlsen,R.E.H.S. Stockton, California 95202-2708 <br /> Douglas W.Wilson,R.E.H.S. <br /> • C4�/FORaP Progru»n hl�,»o,er Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Laurie A.Cotulla,R.E.H.S. Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Program Manager Mark Barcellos,R.E.H.S./ A EMERGENCY RESPONSE RECORD �f <br /> DATE: l lz!11'f' SHORT TERM# 00Cl In <br /> PREMISE ADDRESS: f � �w` f-Exfi CITY: <br /> DBA: ()ivl�l Fi C49 4-p4HAL /W <br /> PREMISE OWNER: UP,[�RL— Gam[ � e'rL PHONE: <br /> OWNER'S ADDRESSL _�,Hfn/1/AM�� x�IT �(Z' l RL <br /> FACILITY CONTACT ALBS k&4.r—�� PHONE <br /> RESPONSIBLE PARTY(RP)DBA (&L%Z P&IM 4V4A� <br /> RP NAME UAI(OtQ aVLF4)A 2 PHONE ?— <br /> RP ADDRESSAA �/-S I- <br /> RP CONTACT ARL s A Y A"�S PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> :e Vim. 0-1�r 4�Lf-'PL/1 - 'Q'� <br /> TIME RECEIVED 04��30 TIME OF ARRIVAL T�-- v0-0 TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> SikQTrA-= /, (C70)897/-"71 �- <br /> ��y��lael�ci <br /> IDENTIFICATION OF MATERIAL(cHENITCALrNVOLVED) S <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 /> E.Ig. BINDER COPIES: <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 /> 6/14/1999 <br /> Documentl <br />