Laserfiche WebLink
State B/California—Environmental Protection Agency Department of Toxic Substances Control <br /> COMPLAINT REPORT FORM <br /> (Use ball-point pen) Log Number., I ' <br /> INFORMANT ALLEGED RESPONSIBLE PARTY <br /> Name: /' "' Name: <br /> <br /> <br /> <br /> <br /> ` - ' -�- City: ZIP: <br /> LA Confidential OR ❑ Anonymous: (Check one) County Code: Phone: ( ) <br /> COMPLAINT DATA <br /> Is this an emergency? ❑ Yes Q No If yes, call the Office of Emergency Services (OES): 800-852-7550 <br /> Log Number: - - Date Complaint Received: ' / - Time: /J cr .+ Received By: ::7,- <br /> Notifications made (Yes/I(o),Orop. 65 Local Agency Who? <br /> Date of Incident: - -r• Allegation Code: �/ Quantity: - �• <br /> Type/Condition of Containers Visible: <br /> Source of Complaint/Code: If Code A, Specify: <br /> Other Comments: <br /> COMPLAINT COORDINATORS ONLY <br /> Response Code - Region/Agency Referred To: <br /> Response Date: Investigator: Date Assigned: <br /> Note: Information to be transferred to complaint log is highlighted in bold italic print. Attach an addendum if necessary. <br /> See code on reverse side. <br /> White Regional Office Yellow—Log Pink—Investigations Green—Informant <br /> DTSC 1017 (10/61) <br /> (Formerly DHS 6231 end DHS 8073) vi 93M <br />