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PUBLIC HEALTH SERVICES <br /> FOUL. <br /> SAM JOAQUIN COUNTY �°' a` <br /> ENVIRONMENTAL HEALTH DIVISION r <br /> b X <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 304 E.Weber Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 <br /> 209/468-3420 <br /> CONFIDENTIAL <br /> PERSONAL TOSIC SUBSTANCE ESPOSURE RECORD <br /> * Substances not considered CO 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 <br /> Address ZZ 1 F _ ttti _# CqL-_ City/Zip SZ-0 Z_ <br /> Home Phone 7z)9. 4A7- VN. 30 Work Phone zo5- <br /> Occupation/Agency z <br /> Title/Assignment <br /> Date & Time of Exposure G _ 16- '6 7: An PM <br /> Address (or best derscrinti.dn) of Incident l� /�tnr4 cl sfaru <br /> Co-wo kers on Scenel �gt ,r <br /> Response Number (CHP, Fi�S¢, O. E . S . , <br /> Short Term Number r"?p CTO <br /> Type of Material : <br /> Name __ *' d . <br /> D.O .T. r# <br /> Form: 49 -L i Powder Granule Fog Gas Mist Smoke Other <br /> Describe How You Were Exposed: Ski Inhalation Ingestion <br /> Amount G _ ,� n Zl . uAn <br /> Detas/S to/ms <br /> Approxima Length of _ osure <br /> On Scene Monitoring/HazCat Findings <br /> Physician Name (if visited) � > :_ z v /�rY� <br /> Physician Address _S cJ. Jd7'&_r7zt City/Zip S <br /> Physician Phone C!�G _,= e-n Date Seen 6 <br /> Diagnosis and Type 'ofTreatment <br /> Miscellaneous Details <br /> A Division of San Joaquin County Health Care Services <br />