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&[ME984 <br /> 24 HOURSP.O. BOX 740 <br /> ONTARIO, CALIFORNIA 91761 <br /> T SAN JOAQUIN LOCA" 987-5005 Business Office = <br /> HEALTH DISTRICT <br /> PLEASE ADVISE WE T.I.P. OF ARRESTS / CONVICTIONS / DISPOSITIONS <br /> PRIMARY AGENCY: Case#TC <br /> Address : Phone ( ) <br /> City County State ZIP <br /> SECONDARY AGENCIES: SANITARIAsi <br /> Date call received: Time: Referral Media <br /> Date Agency called: Time: Phone( ) <br /> Spoke to: Agency <br /> SUSPECT#1-Name Dr. Lic.# <br /> Address Phone( ) <br /> city County State ZIP <br /> Sex Race Age D.O.B. Hair Eyes Hgt. Wgt . <br /> Marks/ Clothing <br /> How involved in CRIME? <br /> Vehicle: Yr. Make Model Color Lic.# State <br /> Marks/ I.D.# <br /> Name of Carrier: Phone( ) <br /> Address _City <br /> crime : Date/Time <br /> Location of Incident City <br /> Nature of Incident <br /> Chemical Names & U.N. Numbers <br /> Description of HAZARD <br /> FORM: ( ) Liquid ( ) Powder ( ) Gas ( ) Solid ( ) Sludge ( ) vapor <br /> CONTAINER: ( ) Bulk O Tanker ( ) Barrel ( ) Bags ( ) Other <br /> Quantity Spilled Area of contamination <br /> PAVED: ( ) Asphalt ( ) Concrete Condition: <br /> UNPAVED: ( ) Hard Pack ( ) Sandy ( ) Gravel ( ) Other <br /> Adjacent land uses: ( ) Residential ( ) Commercial/Business ( ) Industrial <br /> ( ) Roadway ( ) Agricultural ( ) Other <br /> Firm Name Phone ( ) <br /> Address City <br /> Type of business__ <br /> No.of people exposed Symptoms <br /> Informant will call back Called before Referral# REWARD <br /> Above information may be incomplete. All questiol .... TIP forwards all <br /> information without screening. - 0 # <br />