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11 <br /> State of California—Environmental Protection Agency Department of Toxic Substances Control <br /> COMPLAINT REPORT FORM <br /> (Use ball-paint pen) Log Number: <br /> INFORMANT ALLEGED RESPONSIBLE PARTY <br /> Name: ��:/— <br /> <br /> <br /> <br /> city: r<_ ZIP: <br /> ❑ Confidential OR ❑ Anonymous: (Check one) County Code <br /> ' Phone: <br /> i <br /> COMPLAINT DATA <br /> Is this an emergency? Yes ❑ No If yes, call the Office of Emergency Services (OES): 800-852-7550 <br /> Log Number:I_f,� ?-c t " bate Complaint Received: -7ht Time: �'r__0 Received By: i�'r'��1'� <br /> Notifications made (Yes//No) <br /> f Prop. 65 nrC Local Agency Who? <br /> Date of Incident: Allegation Code*: Quantity: <br /> Type/Condition of Containers Visible: 7ANk #V9 fE VA-4 - <br /> 0 Source of Complaint/Code;: Code A, Specify: <br /> Other Comments: CLA4 Fr,J4 NE 7tr"' ,-F i e j + r t i?l y fj4- E_ri)- C rJ f~' ` Anlr AVEl'.t0e_1jizjfurz,,, ,j,j ,'tel-,)A-j '4 rA t, *> <br /> ' Aw <br /> o ;r _" r MN —Ww , XT €pE ',a1 < F+ 1A#1 1. : i J] t r REAR ! . Ot r:_n/. )T �4� 1_ i +A AA,;6\j <br /> �` + t1Ata lrJtn lu, rstlrA L.i/11�� #�r' Prri r/,` 1_94 _ l.11 f-THE VAA1 <br /> r lt�.rJ11 1 '' _ r t IPE C- , r _; i. 1, ( L^.,f;'i f, , tE ?�1;�+f�'t7- C td %t' ?v 4 F�Lt t.liE '' E <br /> 'WyfhT A . i 1 ` +,} ':7 J r;f LjkA' ,, - 2 0'(h,,Jjk,,jR r1Wr A 4-) Za L.L. o,5 1\.1413E A iV, <br /> 14:-A4 3 r fIT': r� ,) l r_ 1 <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(10191) <br /> (Formerly DHS 8231 and DHS 8073) 91 93088 <br />