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San Joaquin County <br /> Environmental Health Deonna HS <br /> partment ASSISTANT DIRECTOR <br /> 600 East Main Street Laurie Cotulla,REHS <br /> Z <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> Cad Borgman,REHS <br /> Mike Huggins,REHS,RDI <br /> Website: www.sjgov.orglehd Margaret Lagorio,REHS <br /> Phone: (209)468=3420 Robert McClellon, REHS <br /> Fax: (209)464-0138 Jeff Carruesr-o, REHS, RDI <br /> EMERGENCY RESPONSE RECORD Kasey Foley,REHS <br /> DATE: SHORT-TERM#: <br /> PREMISE ADDRESS: t(ol--777 Poki CITY: r-4)10- <br /> DBA: R 'Si/yIP10- C42 - <br /> PREMISEOWNER: x PHONE: <br /> OWNER'S ADDRESS: S-Prfk., k� <br /> FACILITY CONTACT: PHONE: 6q I 3 -fL-( <br /> RESPONSIBLE PARTY(RP)DL <br /> RP NAME: PHONE: <br /> RP ADDRESS: <br /> RP CONTACT: PHONE: <br /> NATURE OF COMPLAINT(explosion, spill" leak, fire, or abandoned/dumped t 1) <br /> -A v!K10it, 'W1e4 (-A'Ljr.Si'X Ld/4' <br /> A b f h i9f) �o Z. Ov <br /> TIME RECEIVED: 1 0 TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> —C) <br /> IDENTIFICATION OF MATERIAL(OMWCALINVOLVED*-=---�� <br /> SUBSTANCE FORM ❑SOLID [I POWDER -EIGAS '�IQUID []GRANULE <br /> REFERRALS TO: I DATE MAILED: <br /> DATE COMPLETED........PROP 65: 0121 I'm UAR: <br /> t <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> 16 Vi <br /> V—T <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED) ❑ YES <br /> E.R. BINDER COPIES: <br /> 2 HORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA ROP 65/UAR <br /> EXPOSURE RECORD MANIFEST ❑ CLEAN UP REPORT TkER AGENCY REPORTS <br /> rl: 8 t <br /> r❑1 REFFRRALS T97MAP ❑ FILEICREATED <br /> Document Page: lof3 6/14/1999 <br />