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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> .o <br /> ENVIRONMENTAL HEALTH DIVISION a z <br /> i < <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 /> PERSONAL 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 5-20 years to develop in humans . <br /> * <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 Diva' ' -the <br /> NIL <br /> letterhead address above. CORATIE <br /> Name <br /> Addressa City/Zip S <br /> Home Phone zo _ V_43 wcr. Phone w r/ <br /> Occupation/Agency _ - Tot ., n r i ' am <br /> Title/Assignment <br /> Date & Time of exposure _ L - 5( :0-7-0 h . <br /> Address (or b � descr_pt_en) of Inti dent • /H ka <br /> Co-workers on S(zlene n/rnn 2 <br /> Response Number (CHP, Fire, O.E. S . , etc. ) <br /> E .H. Short Term Number Cc 00 175/ L <br /> Type of Material : <br /> Name <br /> D.O .T. # ' <br /> Foran: i Powder Granules Fog a Mist Smoke Other <br /> Describe How You Were Exposed: Skin a ati ingestion <br /> Amount rltiu wn)n <br /> Details/Symptoms <br /> Approximate Length of Exposure 7- <br /> On <br /> On Scene Monitoring/HazCat Findings .� <br /> / <br /> Physician Name (if visited) z . <br /> Physician Address City/Zip <br /> Physician Phone Date Seen <br /> Diagnosis and Type of Treatment <br /> Miscellaneous Details <br /> A Division o1 5an Joaquin C.mnty Health Care Services <br />