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San Joaquin:County DIRECTOR <br /> o u l N Donna Heran, REHS <br /> Environmental Health Department ASSISTANT DIRECTOR <br /> 2' ;y 600 East Main Street Laurie Cotuila, REHS <br /> N % <br /> s Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> •: Carl Borgman,RENS <br /> Mike Huggins,RENS,RDI <br /> Igov. <br /> Website: www.s or sg <br /> 9�ehd Margaret Lagorio,REHS <br /> Phone: (209)468-3420 Robert McClellon,REHS <br /> Fax: (209)464-0138 .left Cainresco,REHS, RDI <br /> EMERGENCY RESPONSE RECORD Kasey Foley,REHS <br /> DATE: Ll 3 ` Z SHORT TERM fi:. C 40 0b 3 <br /> , <br /> PREMISE ADDRESS: Ivs 0 bU{^}-f`1� h- f CITY: S� G v_�Pj <br /> DBA:_C D r'i-� Pr pDy&L j CA L F Ka- sy; <br /> PREMISE OWNER: PHONE: <br /> OWNER'S ADDRESS: F /9 <br /> FACILITY CONTACT: Q D�r� 4 j' �' _.. PHONE: VLI rJ ,18P 3? <br /> RESPONSIBLE PARTY(RP)DBA: S n'�-' Al Q20AA1 <br /> RP NAME: PHONE: <br /> RP ADDRESS: . <br /> RP CONTACT: PHONE: <br /> i <br /> NATURE OF COMPLAINT(explosion,spill, leak, fire,or abandonedldumped material) <br /> ��. a eQ � <br /> TIME RECEIVED: L400 TIME OF ARRIVAL: `_r .p TIME OF DEPARTURE: ' 3I <br /> PERSONS AT SCENE N <br /> NAME AGENCY PHONE TOA TOD <br /> ar T F r A k L Grin P fftuy <br /> r <br /> - IDENTIFICATION OF MATERIAL(cto:nncw uwoz.crn) <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ' .[] GAS LIQUID []GRANULE <br /> REFERRALS TO: DATE MAILED: <br /> DATE COMPLETED........PROP 65: y UAR: <br /> PERSONS EXPOSED and/or INJURED <br /> NAME _ ADDRESS PHONE <br /> 1 "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? YES NO <br /> E.R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE ❑ ANALYTICAL DATA PROP 65/UAR <br /> (. EXPOSURE RECORD MANIFEST ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS. <br /> a ❑ REFERRALS `�MAP ❑ FILE CREATED <br /> DocumenH Page: l of 6/14/1999 <br />