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...,..-,<, ....--•..............r, -r^^.,..�rrmrmr*�.^.a-1T*'F`:^'Tr....tr,t...,.-,..�mvr...,m-^'.--1r�1!'z_'..T�7.m,gwr+.-rr,?nrtnlr ws!.'E-^•p,?`7�1�'S -rfl� `, r,Pi,:rC?Ti�?"" .. r. ., - �°�T. _. <br /> State of California--Environmental Protection Agency b@pattrtient of Toxic Substahces Control <br /> COMPLAINT REPORT FORM q <br /> (Use ball-point pen) 'Log Number <br /> INFORMANT ALLEGED RESPONSIBLE PARTY <br /> Name:_ <br /> <br /> <br /> " City: r ..v . "' '`»�"` ZIP: <br /> Confidential OR ❑ Anonymous: (Check one) County Code.. <br /> Phone._( <br /> COMPLAINT DATA <br /> Is this an emergency? ❑ Yes ❑ No If yes, call the Office of Emergency Services (OES) x'.800-852-1550 <br /> Log Number: 4��(r�wate Complaint Received: I .t Time: CSC# '____ Received by:'�(. <br /> Notifications made (Yes/No) Prop. 85 —Local Agency Who? <br /> Date of Incident: Allegation Code: b "' Quafltity: _ <br /> Type/Condition of Containets Visible: <br /> Source of Complaint/Code If Code A, Specify: <br /> I.> <br /> Other Comments: i VN-�'a <br /> V'� ►<. ��, �.1`� aC. tliL: ,: �'� � "� losi <br /> IQ <br /> COMPLAINT COORDINATORS ONLY �. <br /> Response Code: Region/Agency Referred To: <br /> Response Date: Investigator: Date Assigned: <br /> Note: Information to be transferred to complaint tog Is highlighted in bold italic print.Atiach an'addendumi if necessary. <br /> 'See code on reverse side. <br /> White—Regional Office Yellow—Log Pink-investigations Green—Informant <br /> DTSC 1017 (10/91) <br /> (Formerly DHS 8231 and DHS 8073) vi s30R9 <br />