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3- <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> - SAN JOAQUIN COUNTY <br /> 2' ? DUnit Supervisors <br /> Donna K.Heran <br /> ,R.E.H.S. P <br /> man,R.E.H.S.b <br /> Weber eer Avenue, Third Floor Carl Bor <br /> Director 304 Eg <br /> r 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 g <br /> <rFOR�' Laurie A.Cotulla,R.E.H.S. Telephone: (209) 468-3420 Margaret Lagorio,R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD Marc Barcellos,R.E.H.S. <br /> DATE 2 Z d O SHORT TERM# 66 2 �� Z <br /> PREMISE ADDRESS 1370 N , M &j " /- CITY Af <br /> DBA <br /> PREMISE OWNER P M v LQI PHONE <br /> OWNER'S ADDRESS C j $ r <br /> FACILITY CONTACT 5A Ori A PHONE u66 <br /> RESPONSIBLE PARTY(RP)DBA <br /> RP NAME PHONE <br /> RP ADDRESS <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> Khu�� f n A 6o r 'ir- 1 "� n rnE n h <br /> TIME RECEIVED TIME OF ARRIVAL —7 i TIME OF DEPARTURE lCf 6,91 <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> Cv,c lL if, S, 1r , . L,16 f - 00-7 -— 7.� <br /> RDZA+v f,.j NS k� Mer-, 14L7— 3111 <br /> Lf 16 6car <br /> IDENTIFICATION OF MATERIAL(CHEh9CAL INVOLVED) o N Kn <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS ❑ LIQUID ❑ GRANULE <br /> REFERRALS TO DATE MAILED <br /> DATE COMPLETED............PROP 65 UAR <br /> PERSONS EXPOSED and/or INJURED <br /> NAME ADDRESS PHONE <br /> "PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES NO <br /> E,R.BINDER COPIES: <br /> 'K 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 /> EH22014rev 6/14/1999 <br /> a <br />