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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Donna K.Reran,R.E.H.S. Unit Supervisors <br /> 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Director <br /> At Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> Program Manager Douglas W.Wilson,R.E.H.S. <br /> Telephone: (209)468-3420 <br /> Laurie A.Cotulla,R.E.H.S. Margaret Lagorio,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 /> EMERGENCY RESPONSE RECORD <br /> DATE SHORT TERM# <br /> PREMISE ADDRESS- CIO Pw)LA 4CL CITY _1LTbC"bf1j' <br /> DBA 9h;w <br /> PREMISE OWNE� PHONE <br /> OWNER'S ADDRESS 101110 U&A R-4r>PfQ <br /> FACILITY CONTACT Pd &rWj6qdMb4 PHONE. <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 /> Aff 1411 &6nd d <br /> TIME RECEIVEDn TIME OF ARRIVAL TIME OF DEPARTURE, <br /> PERSONS AT SCENE <br /> NAME AGENCY PRONE TOA TOD <br /> IDENTIFICATION OF MATERIAL p'7'NvoLvED' <br /> SUBSTANCE FORM 13 SOLID El POWDER IJ GAS NLIQUID CIGRANULE <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? 11 YES 0 No <br /> E.R.BINDER COPIES: <br /> 13 SHORT-TERM ON TOP 13 NARRATIVE 13 ANALYTICAL DATA 13 PROP 65/'UAR <br /> 13 EXPOSURE RECORD 13 MANIFEST 11 CLEAN UP REPORT 13 OTHER AGENCY REPORTS <br /> 13 REFERRALS 11 MAP 11 FILE CREATED <br /> EH22014rev 6/14/1999 <br />