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CONFIDENTIAL <br /> PUBLYC HEALTH SEMICES <br /> SAN JOAQUIN COUNTY z <br /> N: :< <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 (1601 East Hazelton Avenue) Stockton, California 95201 <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 /> Namec_le <br /> Address _ 1, 1219, r- VGA s City/Zip <br /> Home Phone Work Phone 2e— 7*2-- -5-0 7 <br /> Occupation/Agency M. •�� •� N <br /> Title/Assignment A <br /> Date & Time of Exposure <br /> Address (or best description) of Incident 5 <br /> �.r <br /> Co-workers on Scene <br /> Response Number (CHP, Fire, O.E.S , etc. ) is /2 <br /> E.H. Short Term Number 9Q/99:2- <br /> Type of Material: <br /> Name �dl ti <br /> D.O.T. # <br /> Form: Liquid Powder Granules F st Smoke Other <br /> Describe How You Were Exposed: Skin Inhalation Ingestion <br /> Amount <br /> Details/Symptoms rhe— kasraar � <br /> Approximate Length of Exposure Z6-75- <br /> On <br /> O_7j-"On Scene Monitoring/HazCat Findings <br /> Physician Name (if visited- "a %► <br /> f: Physician Address 5zs- LJ. 4CC-4C-f'4 __ City/Zip �ldcr- f�,.� C-4 <br /> Physician Phone -.31 Dote Seen leo <br /> Diagnosis and Type of Treatment u <br /> Miscellanea s Det ils r - u <br /> EH 22 020 5/90 <br /> A Division of San Joaquin County Health Care Services <br />