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PU <br /> B HEALTH <br /> L <br /> SAN JOAQUIN COUNTY ° <br /> a: .a <br /> JOGI KHANNA M.D.,M.P.H. ` <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) . Stockton, California 95201 cQlkijaN:P <br /> h (209) 468-3400 <br /> PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD i <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 /> 1` 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 dy-Nesl_r-e_ve .fie`?- <br /> Address G S I City/Zip S ys2ro� <br /> Home Phone 109 -Y3- '709YWork PhonM4T--2'x2- /5-0D <br /> Occupation/Agency /j1xrl' pear c/M /I/�.vu7c'ur�uri _ <br /> Title/Assignment <br /> Date & Time of Exposure o AM I0 <br /> Address or best description) of Incident <br /> Co-workers on Scene -w- v <br /> Response Number (CHP, Fire ,16.-E.s. 3 etc. ) ' t/S I <br /> E.H. Short Term Number d <br /> Type of Material: - <br /> Name Pv <br /> D.O.T. # <br /> Form: Liquid Powder Granules Mist Smoke Other <br /> Describe How You Were Exposed: Sk' Inhalation Ingestion <br /> Amount G 1 <br /> Details/Symptoms crf�ii <br /> /pl�P i/7'f7 /') . <br /> Approximate Length of Exp sure <br /> On Scene Monitoring/HazCat Findings <br /> Physician Name (if visited) o, <br /> vc S' d <br /> Physician Address G✓. c city/ZipS 3 <br /> y <br /> Physician Phone V - 2 Date een <br /> Diagnosis and Type of Treatment <br /> Miscellaneous Details N620A ZQ42�2 <br /> C _. t! <br /> EH 22 020 5/90 <br /> F <br /> A Division of San Joaquin County Health Care Services <br />