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v <br /> = 11111INTIAL <br /> PUBLIC HEALTH SE ICE <br /> SAN JOAQUIN COUNTY z' <br /> JOGI KHANNA M.D.,M.P.H. _ z ` <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) Stockton,California 95201 <br /> c4C�Foai�`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 <-VeAh-'j <br /> Address 3a sz� Ate-> C City_ /Zip !�a-kN 95.E/o <br /> Home Phone Work Phone 204 ,- 9&,2-1s_o_n <br /> Occupation/Agency C <br /> Title/Assignment P , <br /> Date & Time of Exposure W144b ^' 3.'30-S: Cao I-A4 <br /> {{ Address (or best description} of Incident S A S <br /> Co-workers on Scene <br /> 4. <br /> Response Number (CHP, Fire, <br /> E.H. Short Term Number 70/97;z- <br /> Type <br /> O .2Type of Material: <br /> Name .✓ r <br /> D.O.T. # <br /> { Form: Liquid Powder Granules FIRGas) Mist Smoke Other <br /> Describe How You Were Exposed: Ski Inha a ion ngestion <br /> Amount N <br /> Details/Symptoms C rC <br /> Approximate Length of Exposure s <br /> on Scene Monitoring/HazCat Findings <br /> Physician Name (if visited) Dr �rr�'rN fir^ I�c�sS <br /> Physician Address 52<-- f✓• - City/Zip C>� <br /> Physician Phone --3 '� Date Seen <br /> Diagnosis and Type of Treatment �&Z -/2- .y.1, <br />� I <br /> Miscellaneous Details e u f9 d z <br /> F a 5 S s C ^ <br /> G� wl ry i`rra <br /> i <br /> q5 fd5-Lp <br /> 4, <br />} EH 22 020 5/90 <br /> 4 <br /> A Division of San Joaquin County Health Care Services <br /> I <br />