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k <br /> ACCIDENT REPORT FORM <br /> Page 1 of 2 <br /> Initial Site Investigation <br /> f; <br /> at the <br /> Exxon Retail station No. 7-3330 <br /> 3228 West Benjamin Holt Drive <br /> Stockton,California <br /> A�. <br /> EMPLOYER <br /> 1. Name: <br /> 2. Mail Address <br /> (No. and Street) (City or Town) (State and Zip) <br /> 3. Location, if different from mail address: <br /> -�NJURED OR ILL EMPLOYEE <br /> 4. Name: <br /> (first) (middle) (last) Social Security#: <br /> 3 <br /> 5. Home Address: <br /> x. LA (No. and Street) (City or Town) (State and Zip) <br /> .k 1 <br /> 6. Age: 7. Sex: Male <br /> ( ) Female ( ) <br /> 8. Occupation: <br /> (Specific job title, nit the specific activity employee was performing at time of injury) <br /> 9. Department: <br /> (Enter name of department in which injured person is employed, even though they <br /> x may have been temporarily working in another department at the time of injury) <br /> i' <br /> THE ACCIDENT OR EXPOSURE TO OCCUPATIONAL ILLNESS <br /> 10. Place of accident or exposure: <br /> to (No. and street) (City) (State and Zip) <br />:a <br /> 11. Was place of accident or exposure on employer's premises? Yes ( ) No ( ) <br /> r: <br /> 12. What was the employee doing when injured? (Be specific -- was employee using tools or equipment or <br /> handling material?) <br /> I73.19.Ri 3/6/91 <br />