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:ASE TYPE ALL INFORMATION,IF POSSN" - - <br /> State of Calltomia MAIL ORIGINAL D�WV�CTLY TO: MAIL 2 COPIES TO: ' <br /> EMPLOYER'S REPORT Dept' Of Industrial Relations Gates McDonaicl OSHA Case <br /> Div. of Labor Statistics 1330 Broadway. Suite 1630 or File No. <br /> OF OCCUPATIONAL P.O. Box 603 Oakland: CA 94612 <br /> San_FranCtsco, CA 94101 4151832-0301 <br /> INJURY OR ILLNESS <br /> -RA LUUX <br /> ELIrEfa X X rYPEWRITER ALIGNMENT GUIDE <br /> PICA <br /> ,liforma law requires an employer to report WNhfn five days every rndustnal iniury or occupational dfseaae wntch:fa}Results in lost time beyond the tlsyat iniury, <br /> (b) requires mearcat treatment other than first aid. PLEASE NOTE: In addition. If death results or It the iniury o-Illness:(a) Requires rnoauent hosmahMorl of <br /> tie than 24 hours for other than mediCall observation: or (b) results in loss of any member of the body: or (c) Produces anv serious Degree of permanent <br /> figurement.men me nearest distrtcr office Of the California Division at Occupatlohal Safety and Health also must be not bed Inuheaiatsly Dy teteptrorw or telegraph: <br /> is notiftcation is not required, however,d the injury or death results from an accident on a public street or highway. <br /> t-FBMt NAM@ <br /> OWENS-BROMAY GLASS CONTAINERS "`Pt><ICY NUMBER AY NOT <br /> USETMS' <br /> 2.MAN-M ADOFESS INurICw rid etgR:cAy.aPt COL LNN- <br /> P.O. BOX 30 Tracy, Ca 95378-0030 u209 NUMBER 6-8200 CA=NO. <br /> 7 LOCATION.IF DIFFERENT FROM MAIL*AXMM lrl OMW&W Boast.QN.aM 311.LOCATION CODE <br /> 14700 W. Schulte Road Tracy, Ca 95375 0022 <br /> aA.NATURE Of Bu � a+ <br /> aQ..D4wrde"..vNrdrrlrpoeu:�awrrlst,rldeM.� *WNE WP- <br /> Manufacturers Of Gass Containers - S.STATS UNEMPLOYMENT INSURANCE ACCT.No. <br /> 49.TYPE of EMPlpYER• - 342-5747-5 <br /> PPW4W E' STATW CITY coUMY DiS OTHM GOVERNMENT—SPEWY INtrlitfRAr' <br /> X <br /> e.EIrPLOYyE NAME - �If 7.D � <br /> ATE OF BIRTH IMMYY1 <br /> r fl U � , OCWVATION <br /> e.MOMIG ADORRESS (Numo6r ab ZIPI sA.PHONE NUMBER � <br /> 9.SES Fu 11" 1*.OOCUP�! IOQRM.not pmw Of mhuyt 1 t-SOCIAL SECURITY NUMBER _ <br /> 12.DE1ARTylE_ IN <br /> WHICH AEOULARY ErAPIOYEO- 11A.DATE OF HITYt A� <br /> lU$U* � <br /> 17.HOMO USUALLY YrORIffD:1k]URS PER DAV 13A.-DAYS PER WEEK 12L 10TAL WEEKLY MOURS 1x'���r �aRE 00"i <br /> � 0�'O4� QAN�NOURS <br /> POW wrw wags a"q"s <br /> 8 5 40 _ x, <br /> 14 GROSS wAGESISALMn Pari- HOUR DAY YMM TWO WEEKS MONTH OTHER—SPECEFY <br /> �- <br /> X nArra Part Wulf <br /> 'S.WHERE 010 AC=Mr OR EXPOSUM OCCUR?IMlmdor any edrrr,c ryt rya COUNry 151111ON EMPLOYER'S PREMISES? <br /> 14700 W. Schulte.Rd. , Tracy Ca Sart Joaquin YES X 0 wIRMY HOURS <br /> '6 WHAT WAS EMPLOYEE DOING WHEN f*Igywpr mp; <br /> MwOrelfw�wr u�rq � ��i'--L� <br /> wlttllaY:WAGE <br /> "HDw aD THE ACl70ENT OR EXPOSURE OC, m IPMwta dares AMIr rM dwnrs 1reH ,d.rn <br /> PMal am rfr~1M MMRd nwraydwNr,1- •NW V or OCC= drarww, [",*W r4o0wrMd f1d rprw napoelyy: - <br /> COUNTlr <br /> NaLvwwaaxw <br /> a.OBJECT OR SUBSTANCE THAT b1RECTLY'lN.rURED EMPLOYE!?•.q., list macwMa5 Elis <br /> onruer eWst mwd m ria st aa, I°UeK. rgpor or poeW nnwo of r+.rra..d:u+r <br /> PART CW BODY- <br /> . <br /> :9A.DESCRIBE THE bLA1rtY DR 11.L.61P.ae A.q..or..ltr�Yr,,.twpya"rem.few. 14e.PART OF BODY AFFEC lEp A.q..4Aet 1st wwr,nqm my*.wc. 1 . <br /> SOf111C[` <br /> !Q.NAME AND ADDRESS OF PHYSICIAN 14rwoorwa S~.Cay,ZIP) <br /> 445 'W. Eaton Ave Tracy, Ca 95376 ACPMWtI TYPE <br /> !1 IF MOSP1TAt771�.NAME AND ADDRESS 7OBPfrAL iNWftwtow a1rer.Cary.Z M <br /> 2 DATE OF1FUURY OR fLLHEO r <br /> .m"4DC.YY1 23-TLE OF DAY a.m. ., p f,*! 24.01d rrwwom er r rw aM%A daVe wonr !I-We mnry► <br /> NM-00-YY1 <br /> YES-0w last Wor4e; <br /> S.HAS EMPLOYEE <br /> RETURNED TT♦\��O WORK?' iT�MOp.1^r1 21L010 EMPLOYEE VIP? {MM4DO•YY) EXTEffoF . <br /> No.etitl oft Trom- ,-due rpgHed:,- <br /> rnd a Irypd a onn S,p�r. <br /> uld DAy.. <br /> Pett <br /> Coyle ' P1 ant '`- <br />