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State of California—Environmental Protection Agency Department of Toxic Substances Control <br /> COMPLAINT REPORT FORM j t/� 1 <br /> (Use bail-point pen) wog Number ! <br /> INFORMANT ALLEGED RESPONSIBLE PARTY <br /> Name: DANIEL- Auf-1 Name: <br /> Address: :s_rV1C0..__ Firm: -.,74h�fL.pC��� �UC1:i1JC- <br /> City: 7Z '711t 7, C'A ^�ZIP: �03 Address: -3397- �5u^ y i�bo b <br /> Phone: City: iZc f CA ZIP: l ?J <br /> ❑ Anonymous: (Check one) County Code*: <br /> LJ Confidential OR �Phone: , <br /> COMPLAINT DATA <br /> Is this an emergency? ❑ Yes �X No If yes, call the Office of Emergency Services (OES): 800-852-7550 <br /> Log Number.I �fir'' '1j `Date.Complaint Received: e� Time: Received By; <br /> Notifications made (Yes/No) Prop. 65 Local Agency Who? <br /> Date of Incident: Allegation Code*:_ . Quantity: - <br /> Type/Condition of Containers Visible: ____.r<AL"e,.In] <br /> Source of Complaint/Code*:—1 If Code A, Specify: <br /> Other Comments: LnAlPIw4 it,4AT L G-RmEr :=M11t-U h E fir~ ARP_- Ae G)ui LE;.A J_sF_ AR t4r QEc i i� Nrxi T LY) <br /> i Nt,k '9J,tJff t1 t.) E l ..f 'r -I"PE EtV V1 V C'tt L /inf.A <br /> if:5 4` t`!1 T 74 2 .l fJ `� f o-- A ) t'� " 1 u r-' w'4 A1M A� <br /> �. <br /> it')UAAP-177E5 1A114!_-UI-b AQP-- <br /> T4- r J <br /> 14 / ' 44L ,"1= -4 1AjAJJj 11RP !fir 011 77, t� lsn �i M t <br /> 2-IL � 42 IJP+ 6 // :i TAI <br /> ) i2 F)l)Vj` AL , FA;ej` to} f - <." r i!t~ 11 r . r� / A <br /> 1A VtA Jk?/.1h ',I ''a, ,-, ,v =EL Tr'' ' '! t I D4l ,K j 1 '' <br /> r F� <br /> COMPLAINT COORDINATORS ONLY tt,l L� C PL j <br /> Response Code`: Region/Agency Referred To: r <br /> Response Date: Investigator: Date Assigned: Y <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 /> DISC 1017 00/$1)" <br /> (Formerly DHS 8231 and DHS 8073) 91 93088 <br />