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P,ccident Report to STATE OF CAL%&NIA ❑ Fatality <br /> DEPARTMENT OF INDUSTRIAL RE NS <br /> DIVISION OF OCCUPATIONAL SAFETY AND HEALTH Daze of Death <br /> MOD Date 1.Repo Ing ID 2.Previous Activity? 3. Evem Number <br /> k-L1 If Yes, Li Yes ❑ No (Identifies this , <br /> u- %5 9506 ® +� enter Type: Number. _ Report) -- <br /> 4. a. ❑ b.Establisl-y�p%�Nam 5.Employer ID(State's opfli <br /> Change? (/�_ 1�.C�' tC'. yt-R- <br /> 6. a. O b.Site Address(Street.City State, ZIIp�) 7.City Code 8.County Code <br /> Change? `�'�D5 t�M.-,1'iC V . .- <br /> 9.Mailing Address(if different)(Street,City,State ZIP) <br /> Indu9try& 10. ype of Businessr 71.Primary SIC 12.No. of Employees <br /> 2L 13 <br /> 13.Ownership(Mark "X" in one box) - <br /> a. yPrivate Sector b. ❑ Local Government c. ❑State Government d {J'Fad®ral'.A3' Onoy�C'.oG�C�"' ilj7t <br /> Receipt �"ar _. 14.Rep ed By - is <br /> 1fi Time AM <br /> a P 17.Job Title , �- phone Number <br /> ^'1 S z�l _ <br /> Emp10-yeq- 7.:, 19.Group Name(.) - <br /> Sits y T. 20.Name and location <br /> Contac <br /> m - --- -- <br /> 4�at, 27.Job Title 22.Telephone Number ---- <br /> CWsaMiwtlon 23.(Mark•'X" in one box) a. O Fatality b. 17 Catastrophe c. 11 Non-Fatality/Catastophe d. Non-Fataltryrt"atastophe <br /> •F.., Reported by Pmfesslonal Reported b m b e <br /> __ or Media Employer or Other Parry <br /> Event -�y'rz; I 24.Event Data 25.Event Time AM 26.Number 27.Number of 28.Number of 29.Number <br /> Desc don <br /> hp pM f Fatalities �� Hospitalized NonnosPQiiij ed Unaccounted <br /> Injuries Inlurles for <br /> rc^ M Yy 30. of E ntv0 re.g.,Fall from scaflulG} <br /> 31.Prelimma '•scriptioc <br /> m:v <br /> r., Name/Address of Injured - ,�j--Aye Occupation -"y <br /> 9ZAI hard <br /> T Acce'ent Description (Speedy Mechanism/CenditirniHazardous Substance,. <br /> C R+x1 1<t� CA\R\ W 1bVIp ItibN // <br /> ''�•' �i.c t�1� S1C� �`.., , >��P6 ,R1rx�E � (2E A � 1�� `�+..I�...A M <br /> Ewhere Injured APR O9 2015 <br /> 'l Employemploye M <br /> e was wetl lo'. ' <br /> Other Law Enforcement <br /> resent at Site �c> 4C ENVIRONMENTAL. <br /> .h X „ Agennios P : <br /> Workers Compensation Insurance Carrier t, �,- 1 !•'�)a'Tu^.cOporlACpIT <br /> (Name&Address): (For Fatalities Only) U/-Ik/,04WA� <br /> "rA <br /> Action dy` 32.1 ppection Planned? if No I33 Supervisors)Pssgnetl 34.CSE/IH Assigned <br /> r 4" <br /> Y. 11 No Reasona Jb Lb �p�po <br /> as Optional Information <br /> Fs r, <br /> if' V.1te i Type IU � `value <br /> RECEIVED <br /> I <br /> >' JAN 15 2015 <br /> I36. TWai <br /> Entnes <br /> 37.District Manager- <br /> signature: 5 V Cato: Telophoom N,jmber ( ) <br /> run r ..ima,, <br />