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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> o v G Unit Supervisors <br /> . Donna K.Heran R.E.H.S. <br /> Director 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> •. Al Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> Douglas W.Wilson,R.E.H.S. <br /> Program Manager Telephone: 209 468-3420 <br /> Laurie A.Cotulla,R.E.H.S. � { } Margaret Lagorio,R.E.H.S. <br /> Fax: (209) 464-01.38 Robert McClellon, .E,H. . <br /> Program Manager Mark Barcellos,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD <br /> DATE V 1p G SHORT TERM# Cvo'D 7#104 <br /> PREMISE ADDRESS_ 530 l` M kRW S'F CITY SjyC4,MAj <br /> DBA TftE STVCJ4),N RGt0D <br /> k PREMISE OWNER PHONE <br /> OWNER'S ADDRESS j <br /> FACILITY CONTACT bg n tmJ 6LAC& PHONE 7401 <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE <br /> f <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) L <br /> Z�00 � 1— - <br /> TIME RECEIVED �• 30 Aw-, TIME OF ARRIVAL TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 14 jfn� <br /> — <br /> 'i�•+ �a . <br /> IDENTIFICATION OF MATERIAL�cwca�asvoLVEn� I <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS PLIQUID ❑ GRANULE 1 <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 3110 1 o UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> i <br /> "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 /> ❑REFERRALS ❑ MAP ❑ FILE CREATED <br /> I <br /> EH22014rev <br /> - 6/14/1999 <br />