Laserfiche WebLink
STATE OF CALIFORNIADEPARTMENT OF PESTICIDE REGULATION <br /> PESTICIDE EPISODE INVESTIGATION REPORT PESTICIDE ENFORCEMENT BRANCH <br /> PR-ENF-127(ESTI I0/91)(R.EV.SJC 1196) Pagel ors <br /> RECEIVED BY RECEIVED FROM REPRESENTING DATEITIME RECEIVED PERSON NOTIFIED DAE <br /> SJC AG Commissioner DPR Enforcement Branch 'tiffany_ Anderson 09-0413/9:37 AM DFA <br /> TYPE OF EPISODE DIG <br /> ❑HUMAN EFFECTS 9 ❑UMONMR4TAL EFFECTS PRIORITY pdVESTIGATION <br /> ©YES N NO DHS <br /> Q PROPERTY LOSS 5 ®OTHER DER <br /> OTHER I.D.NO. COUNTY OF OCCURRENCE I DATE OF OCCURRENCE TIME <br /> INV 13-24 San Joaquin MO 04 DAY 18 YR 2006 AM EPA <br /> CAC <br /> EPISODE LOCATION <br /> San Joaquin Mosquito Abatement District White Slough Site OTD 1 I c""-' <br /> INJGREDICOMPLAINANT INFORMATION I2 I! 3 <br /> COMPLAINT SIGNED DR.V lSLI"ED EXTENT OF TN'MRYIILLNESS ACTIVrrY OF PERtt--S--OW1N F.}(posEDANVOLVED <br /> ®YES [:3 NO [�N!A ❑YFS ❑NO ®NIA ❑Fatal ❑SymPtoms ❑Mixerll oader []Field Workers ®Odwe <br /> Serious Exposed Only ADolicatar Public' +fix lairr Handler <br /> NAME AGE SEX WHS NO. WORKDAYS LOST <br /> Tiffany Anderson F <br /> ADDRESS CITY ZIP PHONE <br /> 2 N Avena Avenue Lodi 95240 (209)625-8587 <br /> MEDICAL FACILITY NAME ❑TREATMENT PROVIDED HOSPITALIZED DATFITIME ADMITTED DATE"CIME DISCHARGED <br /> ©OBSERVATION ONLY YES ❑NO <br /> PHYSICIAN ADDRESS R E C E I N � 'P <br /> SIGNS/SYMPTOMS EXPERIENCED 013 <br /> 2 5 2 <br /> ADDRESS NOVI'1 Y L PHONE <br /> EMPLOYER <br /> PROTECTIVE,MVASURES USEDl RIN <br /> EYES HANDS INHALATION OTHER FNGIIVEEING CONTROLS <br /> ❑Safety Glasses ❑C1otIOAnther Gloves ❑Dust Mask ❑Work Clothes ❑Closed System <br /> ❑Ges [�Chem.Resistant Gloves ❑I/2 Face Respirator ❑Chem.Resistant Clothes ❑Enclosed Cab <br /> Goggles <br /> ❑ oggl ❑Otho ❑Full Face Respirator Ch <br /> ❑ em.Resistant Boots ❑Enc-Cab w/Aix Purification <br /> ❑FyeJSan Glasses ❑None ❑SCBA ❑Ilead Covering []Other <br /> ❑Nona ❑None ❑Other_ Nm <br /> ENVIRONMENTAL OR PROPERTY DAMAGE - <br /> AMOUNT/VALIlH <br /> DESCRIPTION OF DAMAGE <br /> OWNER tDDREss PHONE <br /> ALLEGED RESPONDENT PCA DEALER PILOT GROWER AGENCY OTHER. <br /> NAME PHONF. LICENSFJPERMI'T NO. RECONIAdENDATION MADE <br /> San Joaquin Mosquito Abatement District (209)982-#675 3905063 ❑ s No <br /> ADDRESS EMPLOYER'S NAME :7:::=(209)9824675 <br /> 7759 S.Airport Way Eddie Lucchesi <br /> CITY STATE ZIP EMPLOYRVS ADDRESS <br /> Stockton CA 95206 7759 S.Airport Way <br /> EXPLAIN` CITY STATE ZIP <br /> Stockton CA 95206 <br /> PESTICIDE NAMEIMANUFACTURER EPA REGISTRATION NUMBER CATEGORY DOSE/DILUTIONIVOLUME 11 TREATMENT DATE COMMODITYISITE TREATED <br /> Parasito-S None <br /> EQUIPMENT/MAKE'MO D EIMESC RIP'IION <br /> Summarize the episode including a detailed description of evidence taken(Use Pesticide Episode Investigation Supplemental Report if Additional Space is Nee(ed) <br /> See Attached Documents <br /> RA"C PREPA REPORT REYIEWEDIAPPROVED BY(NAM W- Trl-E) DhTE APP OVED <br /> REPORT PREPARED SY(NA14fFlf1TLE) / <br /> dt DAC. <br /> Kimberly D.Martin Agricultural Biologist 1 Barbara Nueckstca ' kl a 3 <br />