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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Unit Supervisors <br /> Donna K.Heran,R.E.H.S. 304 East Weber Avenue Third Floor Carl Borgman,R.E.H.S. <br /> Director <br /> Al� Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I.Douglas W.Wilson,R.E.H.S. <br /> cq.. .'..•�P Program Manager Tele hone: 209 468-3420 Margaret La orio R.E.H.S. <br /> F 6W Laurie A.Cotulla,R.E.H.S. p ( ) g g ' <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> EMERGENCY RESPONSE RECORD Mark Barcellos,R.E.H.S. <br /> DATE 3,1 I-3lo(e SHORT TERM# <br /> PREMISE ADDRESS W am r,Agh RS*t CDL1T)2A 7)_ CITY "VELA <br /> DBA DtATM 64ft-L' <br /> PREMISE OWNER PHONE <br /> OWNER'S ADDRESS <br /> FACILITY CONTACT PHONE <br /> RESPONSIBLE PARTY(RP)DBA 'rte (, }t?{Zr [,p g7�►1(,�j a�j <br /> RP NAME t+►1(, y0 �,.( _ PHONE 140 9 6 0_7— 1-71_--_- <br /> RP ADDRESS ZL Cl `S—lip) -----.— <br /> RP CONTACT PHONE <br /> NATURE OF COMPLAINT(explosion,spill,leak,fire,or abandoned/dumped material) <br /> r <br /> TIME RECEIVED a ' 3y o1r n. TIME OF ARRIVAL &I-3D Lbw% TIME OF DEPARTURE <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> bk;n ftg k(,! <br /> IDENTIFICATION OF MATERIAL(cHENUCAL INVOLVED) <br /> SUBSTANCE FORM ❑SOLID ❑ POWDER ❑ GAS M<IQUID ❑ 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 /> R.BINDER COPIES: <br /> J 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 />