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` ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 2:" yUnil Supervisors <br /> X Donna IG Heran,RE.H.S. <br /> Director 304 East Weber Avenue, Third Floor cart Borgman,R.E.xs. <br /> Al Olsen,RE.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S,R.D.I. <br /> W.•.OqC%,,,,t,M`. P.� Program Manager Telephone: (209) 468-3420 Douglas MartLagoson,RE.H.S. <br /> FOR -Laurie A.Cotolla,RE.H.S. R.ob�rtM C1e11on,RE.H.S. <br /> Program Manager Fax: (209)464-0138 , <br /> EMERGENCY RESPONSE RECORD Mark Barcellos,R.E.H.S.DATE �'�Z�-t I OIo SHORT TERM# C00024 <br /> Y71 <br /> PREMISE ADDRESS `ZS '{t- 9\ a_,14 CITYfzbnCekirn,f d <br /> DBA IY\a-LA- H r9/ a p <br /> PREMISE OWNER 4 tv� —Aja vt n e l PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACTI,Linn 12E, e�ff PHONE <br /> I/ <br /> RESPONSIBLE PARTY(RP)DBA h 1 r,akA <br /> RP NAME PHONE <br /> RP ADDRESS 5P <br /> RP CONTACT K&,\. Ut o PHoN�9//- y/fa-79 3 <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> 31t m TIME OF ARRIVAL 1{ / <br /> T1MB RECEIVED � (1 n--- TIME OF DEPARTURE 6'/-?&..- <br /> PERSONS AT SCENE <br /> NAME AGENCYAI PHONE TOA TOD <br /> IJ>O�a�t el 6r-Ei 7- �n 6U y- 1"l gra KL k . S c2t1�-- <br /> IDENTIFICATION OF MATERIAL t�acv.wvo�vEu> /.e <br /> SUBSTANCE FORM ❑SOLID ❑/POWDER ❑ G/p IQUID ❑ GRANULE <br /> REFERRALS TO CVIeV2Cif V14. DATE MAILED <br /> DATE COMPLETED............PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> X11 A <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑YES ❑NO <br /> c,R BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ANALYTICAL DATA PROP 65/UAR <br /> ZJ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS <br /> ❑REFERRALS MAP ❑ FILE CREATED <br /> w. <br /> EH22014rev 6/14/1999 <br />