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EASE TYPE ALL INFORMATION,IF POSSMU State of Callfamie MAIL ORIGINAL t]�ittCTLY To. MAIL. 2 COPIES TO: EMPLOYER'S REPORT Dept. Of Industrial Relations Gates McDonala OSHA Case T Div..of Labor Statistics 1330 Broadway. Suite 1630 or File No. OF OCCUPATIONAL San Box 603 oakiand. CA 94612 Sart Francisca, CA 94101 4151832-0301 y INJURY OR ILLNESS °�CtX X X ELI fYPE1NRtTER ALIGNMENT GUIDE PICA - Ilitomra law reowres an ernoloyerto report within live do"every industrial injury or occupational disease wnlch:(a)Results in lost time Beyond the day of iniury, rb)requires meatcat treatment other t"En first airy. PLEASE NOTE.- In addition. If death results or 1t the iniury o'Illness:(a) Requires Inoatrent nosoRa>12apon of ire than 24 hours for other than maofcat observation. or (b) results-In loss of any member of the boar.-or (c) produces anv serious aegree ot'permanent-- Ihguisment.then the nearest district offioe of the"domfa Division of Qccupanonat Salety and Health also most be notified immediately by tefsonorwor telegrapt. is notification is not required,however;it the mtury or death results from an acadent on a Public street or highway. 1.FIRM NAME OWENS-BROCIC4AY GLASS CONTAINERS tA.POLK:YNUMBER PLRASIL00Nor USILI is 2.MAILM ADDRESS (Number SM aueiA.CRY.LPI MSER COLIAW& 2.9, .3 P.O. Box 30 Tracy, Ca 45378-0030 7A u 209) 836-8200 -cAasllto.._ LOCATION_W DIFFERENT FROM tall AOO$q= INutlawaea erAer,City,z7P1 COOR - 14700 W. Schulte Road Tracy, Ca 95376 ]l►•LOCATxw 0022 .A.NATURE OF BUSINESS e.p.,9aeeet0 ea agcm,whiten,9p�,-savor 1.holt,amOwMlIIaFM1 Manufacturers of Glass Containers S.srATEUNEMPL3YMENT4z-b747-61NSL,RANCNO. as.TYPE OF EMPLOYER! SCH L. PRIVATE' STATE CITY COUNTY 01SS to OTHER GOVERNMENT—SPECIFY INOUWML A 8 EMPLOYEE NAME OAT$OF BIRTH fMM.OD-rn OCCMATION e.HOME ADDRESS rHungw .Aho Betio:Cry.11F1 —7 , -, . . BIL N!'N�N�UM�BER s_ Y.SEX 10.OCCUPATION I4 � Iola.not Spec"MrAft in 0-0 a MrAvi ti.SOCIAL SECURITY NUMBER i 12.DWARTNIENT IN WYMCH REgEAaiRY EMPLOYED A�-= tk�p'7ATS DF HIRE�M-0aYY! _ W.HOURS USUALLY WORKED:HOURS PER DAY 13A�DAYS PER WEEK 131L TOTAL WEEKLY HOURS 1 "^�eau t>poe a Yov ,DAL)! . 8 Immo..�.wag-"*W o7 40 , 1i aR033 WAGE.S+SALARV- P@B! HOUR DAY WEEK TWO WEEKS mcfam OTHER—SPECIFY . $ x DMFS pian wEpt S.WHERE 010 ACCIDENT OR EXPOSURE OCCUR?fkumaw Ano stew.G,Iyl 15A.COUNTY 151L ON EMPLOYER'S PREMISES7 - 14700 W. Schulte Rd. , Tracy Ca San Joaquinx wEsar7auRs 's WHAT WAS EMPLOYEE DOING WHEN IWURED�1�bp___ YES V. C/ ° �Tuw.q.l W[EKE7.WAGE +7 HOw r>,D THE ACCIDENT OR EXPOSURE OCCUR?hPNsw decried AMIy me AM1e,Me IhN1 iMe.w r '- Pyr Ye,Norm e,'set•ReesgrY.l nIWY W eaG7eYolY1 4*N IeH icer AOorwe Ana MW napb~- caU1rrr - NAfUMCRtt&AXRr' iR.O&MCT OR SUBSTANCE THAT OIREGTLY 0RXAtE0-EMPLOYEE• q '� •.. Oho wan+mina Ins Ahw.m coon a sly she ry -9.. ufa msctwhe AgrRrl tr n)1xlt tergeA IInR-f+e ssaar tr o®t xlRree a areeowea: pe, - _ �n e,C PART dt:Boor 19A.DESCRIBE THE*LA)"OR 1LLJ4E lre4,CUL ireaL koc sli,ean air_ 190.►ART OF BODY AFFECTED e.g..ries..1MI wrwr:nght ere.wm k r 20 NAME AND ADDRESS OF PH"K U1N IN MMW ane SWee,Cft.bpi .. 445 W. Eaton Ave Tracy, Ca 95376 ACCOEff- E tI IF MOSPrrALt2M NAME AND ADDRESS OF HOSPRAL (NYIIO W"S~.city.ZM 7 DATE OF IWURy OR U.t.NM .MM4D0.YY1 21.TOLE OF DAYam. p.m. 24.Did&now~how r ley ane haA wYs www site,we nRx1R AI e--- 'AM-MYYI NO YES—Der un wwkw. '3.HAS EMPLOYEE RETURNED TO WORK? (MLFOO•'M 20.Oro EMPLOYEE OIET - IMMd6VV} ExtiQITOReNBNtr No.stilt off wont Y9-9;�d/te rQUrn&W Np YES--Daft at aseat %•r,.: C4�, . : 1we0 W Iry9e a mol # ride ,.. ow Pott Co 1e Plant N