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PUBE-C HEALTH SE <br /> SAN JOAQUIN COUNTY <br /> Q: :A <br /> JOGI KHANNA M.D.,MT.H. <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) Stockton,California 95201 <br /> CQ�1 FOfz a`P <br /> (209) 468-3400 <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 5-30 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 fir' <br /> Address City/zip :? <br /> Home Phone 9.Q2 Ve2-6-761ZWork-Phone 2 air" <br /> Occupation/Agency tcC 1 JA N <br /> Title/Assignment <br /> Date & Time of Exposur ' ' <br /> Address (or best description) of Incident zagZSenny <br /> Co-workers on Scene <br /> Response Number (CHP, Fire, .E.S , etc. ) <br /> E.H. Short Term Number <br /> Type of Material: <br /> Name — —'y--[ i� <br /> D.O.T. # <br /> Form: Liquid Powder Granules Fo Mist Smoke Other <br />{ Describe How You Were Exposed: Ski nhalati Ingestion <br /> Amount <br /> Details/Symptoms h a ;✓P <br /> Approximate Length of Expos n- y <br /> rr s r . <br /> On Scene Monitoring/HazCat Findings <br /> Physician Name (if visited) <br /> Physician Address SSS Al. Acctcrc, City/zip <br /> Physician Phone 209­96f -3/ Date Seen / <br /> Diagnosis and Type of Treatment <br />� fa�'2c_ �UimP, �,c..7rii,��i,�M r�,�i.✓3�>�•�Lrt iu --- . <br /> Miscellane us Details <br /> SPP O /• _ r <br /> i <br /> r EH 22 020 5/90 <br />!4 A Division of San Joaquin County Health Care Services ! <br />