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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY Q <br /> JOGI KHANNA M.D.,M.P.H. ` <br /> Health Officer <br /> 09�icpPci`P <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) Stockton,California 95201 <br /> (209) 468-3400 <br /> FERleN;& TOXIC SUBSTANCE EXPOSURE RECORD <br /> * Substances not considered to be a cancer risk at this time may <br /> be defined as a carcinogen in the future. Cancer and cancer- <br /> related diseases may take 5-30 years to develop in humans. <br /> * Individuals who are exposed (suspected or confirmed) at an <br /> emergency response incident should document the specifics <br /> of the exposure within 24 hours and mail or phone in this <br /> information to the Environmental Health Division at the <br /> letterhead address above. <br /> Name 6r Nercc Z dor e r.R. (7,4QL, o erk r <br /> Addresser ll oRkr Fre. a/ /ry/ City/zip <br /> Home Phone Work Phone <br /> Occupation/Agency <br /> Title/Assignment <br /> Date & Time of Exposure .2/r/4/ AM CBeFwe•� s ^o rt a -rte ov a�N <br /> Address (or best description) of Incident /yrirtGn �ar� �. <br /> 6 ;/r, )� s,4u r R. (•,rP� { (,Y /7/on fhr'!a� fTof <br /> Co-workers on Scene <br /> Response Number (CHP, Fire, O.E.S. , etc. ) <br /> E.H. Short Term Number <br /> Type of Material: <br /> Name Pe ureflna P -Ancn <br /> D.O.T. # <br /> Form: Liquid Powder Granules Fog Mist Smoke Other <br /> Describe How You Were Exposed: Skin n alation Inges ion <br /> Amount <br /> Details/Symptoms <br /> Approximate Length of Exposure <br /> On Scene Monitoring/HazCat Findings <br /> Physician Name (if visited) <br /> Physician Address City/zip <br /> Physician Phone Date Seen <br /> Diagnosis and Type of Treatment <br /> Miscellaneous Details <br /> EH 22 020 5/90 <br /> A Division of San Joaquin County Health Care Services <br />