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Py <br /> San Y Joa uin Count DIR ` ,' <br /> q � <br /> Donn eran, H <br /> .� Environmental Health Department).• _mss .O ASSISTANT DIRECTOR <br /> 600 East Main Street Laurie Cotulla. REHS <br /> Q: <br /> w: X -3029 California 95202-3029 PROGRAM COORDINATORS <br /> 1�5Cz. <br /> Carl Borgman, REHS <br /> ., Mike Huggins, REHS, RDI <br /> Website: www.sjgov.org/ehd Margaret Lagorio, REHS <br /> Phone: (209) 468-3420 Robert McClellon, REHS <br /> Fax: (209) 464-0138 .teff Carruesco, REHS, RDI <br /> r, EMERGENCY RESPONSE RECORD K( ol <br /> a�seyFoley, REHS <br /> DATE: D SHORT TERM#: C D Do L u f 1 <br /> PREMISEDDA RESS:I DUU 6 I��IL b CITY: <br /> DBA: <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: <br /> FACILITY CONTACT: PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: U N 10-1 A-o gAll r`p,-n 0 (.( ( t <br /> RP NAME: PHONE: <br /> RP ADDRESS: 61 Lf 1 U 4 � ,) � <br /> RP CONTACT: f �P�n +' orl r'0 D PHONE: <br /> NATURE OF COMPLAINT(explosion, spill, leak, fire, or abandoned/dumped material) <br /> A C A E!�b !?M <br /> AU"J L_n� <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> U N KA,6k-� <br /> IDENTIFICATION OF MATERIAL(CHENUCAL INVOLVED) <br /> SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS LIQUID ❑GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED........PROP 65: d t3 UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> IV <br /> ,,PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES NO <br /> E.R.BINDER COPIES: 19 <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 /> Document Page: I oF3 6/14/1999 <br />