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>pPp U 1 N•cQ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton■CA 95202 <br /> (209)468-3420 Fax:(209)464-0138 Web:www g/ehd <br /> aiiF'oR`' <br /> E./R.BINDER COPIES: <br /> SHORT-TERM ON TOP NARRATIVE AN ICA PROP 65!UAR <br /> L DATA <br /> ECLEANUP OTHER AGENCY REPORTS <br /> EXPOSURE RECORD MANIFEST <br /> REPORT <br /> REFERRALS MAP FILE <br /> CREAT1iD <br /> r - - <br /> I <br /> UVEHICLE GATE PASS APR <br /> Unlilea STOCKTON/FRESNO SIECURITY DATE: 9Rsn <br /> INBOUND Guard Initials OUTBOUND Guard Initials <br /> — <br /> TIME 463TIME OUT: <br /> TO BE COMPLETED BY GUARD TO BE COMPLETED BY CHECKER <br /> IS THERE A PALLET JACK? IS THERE A UG PALLET JACK? <br /> ❑No I ❑Yes manual❑ OR electric❑ ❑No I ©Yes (manual❑ OR electric❑ <br /> Tractor License#: Load: ❑Full ❑Partial ❑Half <br /> (INCLUDE STATE) <br /> Trailer#: Checker Name: <br /> Trailer Condition: ❑Good ❑Fair ❑Poor Remarks: <br /> Tractor#: <br /> Remark ; r& �0- <br /> L �_ M <br /> Cie TO BE COMPLETED BY GUARD <br /> �`I' I''I cj� ��' ,j Iq i �li�pipljuaiiiiiiiviml•ioIiIio�ii�l� ' <br /> I I III <br /> i la Id h i i Iil d I � dnill9lill'I I' <br /> Tractor#: <br /> COIaCI}1lrtlBMCJFABRECi�F+tPANIR' <br /> Lo : ❑Full ❑Half ❑Empty <br /> orifi ' P ITELEP tIp tE'GOMf'RNIAf Remarks: ❑information verified <br /> 3d E <br /> SEE BACK FOR UNIFIED GROCERS POLICY <br /> VEA ATRA S PARA LA POLIZA DE UNIFIED GROCERS <br /> Mike Young ° LEONARD POLIT0 <br /> Supervlsar-Maintenance i �� <br /> �; <br /> myourtq@unifredgrocerscom ; Faciliiiesfrran"sportation Supervisor <br /> ENVIRONMENTAL <br /> SERVICES i,,,Ipolito@nrces.com <br /> OIIYO@nrCe5.COPYi <br /> s ?p - <br /> •SE4CPR fomy:rv/ �.Y <br /> - <br /> 1990 Piccoli Road <br /> Stockton,CA95215 1605 Ferry Point . Cell:{5101 7,74-0305 <br /> TEL 209,931.7al3,(__. Unified Alameda, CA 94501 . Phone: (510)749-1390 <br /> Fax:(510)74974150 <br /> rnx 209.9317,4_4 I. �YDGP�VS9M <br /> CELL 209.649.1183 EMERGENCY RESPONSE <br /> 1-800-33 SPILL <br /> 3 www.unifedgrocers.comi <br /> 1 I �wwW.nrces.00m <br /> ER RECORD MODIFIED Page 2 of 4 — <br /> Y <br /> } <br />