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• <br />ENVIRONMENTAL HEALTIPDEPARTMENT <br />Pa�,N SAN JOAQUIN COUNTY <br />,� • : i ., , , •� Donna K. Heran, R.E.H.S. Unit Supervisors <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 />• c .. v • er <br />Program Manager Douglas W. Wilson. R.E.H.S. <br />q�;FoRe�` g g Telephone: (209) 468-3420 Margaret Lagorio, R.E.H.S. <br />Laurie A. Cotulla, R.E.H.S. <br />Program Manager Fax: (209) 464-0138 Robert McClellon, R.E.H.S. <br />Mark Barcellos, R.E.H.S. <br />c EMERGENCY RESPONSE RECORD <br />zDATE D 1 (1-S SHORT TERM # C0 bb 2 2 7 q3 <br />PREMISE ADDRESS Lfl( C A 1 AVL l e• LoO/ CITY Lob; <br />DBA r( 41,:� C_ i �` 01442, <br />PREMISE OWNER 6hj(_j 4,4% P4 411 �77 bT () • P P PHONE 33 L-7 %s <br />OWNER'S ADDRESS P, 19 t 8 0 )( Pf 1 t IM of 6^1 LY� CA- <br />FACILITY CONTACT - 1(_ Q Mi InS 0- PHONE 2 3 L7 - OG% 7i <br />RESPONSIBLE PARTY (RP) DBA VAin b 14 !ns <br />RP NAME PHONE - <br />RP ADDRESS <br />RP CONTACT PHONE <br />NATURE OF COMPLAINT (explosion. spill_ leak. fire. or abandoned/dumned material) <br />n <br />TIME RECEIVED TIME OF ARRIVAL TIME OF DEPARTU O Dom_ <br />PERSONS AT SCENE <br />NAME <br />M f Ve, ) S <br />AGENCY <br />F <br />IDENTIFICATION OF MATERIAL (CHEWCALINVOLVED) D`/ Sby- � <br />SUBSTANCE FORM ❑ SOLID ❑ POWDER ❑ GAS <br />REFERRALS TO L q , euJ i <br />DATE COMPLETED ............ PROP 65 <br />PERSONS EXPOSED and/or INJURED <br />NAME <br />ADDRESS <br />PHONE TOA <br />7 <br />17 <br />ID ! GRANULE <br />TOD <br />t u <br />n <br />0 <br />9 <br />DATE MAILED <br />UAR %3 <br />PHONE 443 <br />"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD" COMPLETED? ❑ YES <br />E. R. BINDER COPIES: <br />HORT-TERM ON TOP ONARRATIVE ❑ ANALYTICAL DATA <br />❑ EXPOSURE RECORD ❑ MANIFEST ❑ CLEAN UP REPORT <br />❑ REFERRALS %R MAP ❑ FILE CREATED <br />g'PROP65/UAR <br />❑ OTHER AGENCY REPORTS <br />EH22014rev 6/14/1999 <br />