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t STATE OF CALIFORNIA <br /> Referral Report DEPAR71`11 >!'r OF INDUSTRIAL RELATIONS <br /> DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br /> "MOD Date 1.ReportiRg ID 2.Previous Activity? 3. Referral Number ' 902162874 <br /> 1-1 Yes ❑ No Identifies this <br /> r 9506 Enter Type: Number: Referral} <br /> 4. a. ❑ b.Establishment Name 5.Employer ID(State's option) <br /> ' Change? t <br /> 6. a. ❑ b.Site Address(Street, City, State,ZIP) 7.City Code8.County Code <br /> Change? ( ( <br /> 9. Mailing Address(Street, City, State, ZIP) <br /> .In & 10.Type of Business 111.Primary SIC 12.No. of Employees <br /> Ownership <br /> # 13.Owne. hip(Mark"X" in one box) <br /> I a Private Sector- b. ❑ Local Government c. ❑ State Government d. ❑Federal Agency/Code E <br /> Source14.Referred By: 15.Date Received � — -- <br /> ik a. ❑ CSEAH(Within office)/CSE/IH ID LT I f. ❑ Consultation <br /> b. ❑ Federal OSHA g. 0 StatelLocal Government <br /> c.C2�State OSH h. ❑ Media <br /> d. ❑ Discrimination - i. ❑Other (specify) <br /> e. ❑Other Federal Agency/Code - <br /> 16.Source or Co tact(Name, Location,Affiliation,Telephone Number) <br /> 67 <br /> Referral 17.a.Safety b.Health <br /> Classification (1) EJ Imminent Danger ( Serious (3)❑ Other (1)❑ Imminent Danger (2)LJ (3}CJ Other <br /> 18. ❑ Migrant Farmworker Camp <br /> 19.Hazard Description <br /> R ! t �r�is ty 1 f/Vti Ol <br /> I 6111L6111a <br /> l Yom✓(l� r <br /> — - - — --- Cont'd <br /> Referral b.Date Letter Sent: c.Date Response Due: 21.Supervisor(s)Assigned <br /> Action 20.a. ❑ Send Letter a, b. <br /> 22.Inspection Planned? If Yes, If No, <br /> i <br /> El Yes No Priority: Reason: Nb f1 Eh <br /> 23.Transfer to(Name): 24.Ivansfer Date: <br /> i 25.Transfer to(Category): c. ❑Other Federal Agency/Code 3 6 <br /> a. ❑ Federal OSHA1Reporting ID I i I i_..ice 6 U507i d)- KState/Locai Government <br /> g b. ❑ State OSHIReporting ID 9506 R ❑ D❑ e. ❑ Other <br /> 26.Optional information <br /> Type ID Value Type ID Value <br /> MAY 0 7 2007 <br /> 27.Total <br /> Entries <br /> 28.Comments: Standing Inspeptiol7 Dill. <br /> CALASH-90(lass) <br /> CASE FILE OR TRANSFER COPY <br />