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-=ASE TYPE ALL 114FOPMATIDN.IF POSSMUE <br /> State of Callfomia MAIL.ORIGINAL D1CTLY TO: MAIL 2 COPIES TO: <br /> EMPLOYER'S REPORT Dept. Of industrial Relations Gates McDonald OSHA:,Caw_ r <br /> Div. of Labor Statistics 1330 Broadway, Suite 163o or File No. <br /> 0>=OCCUPATIONAL P.O. Box 603 Oakland. CA 94612 <br /> San Franctsco, CA 94101 415/932.0301 <br /> INJURY OR ILLNESS t_ <br /> AICA X X X fLITEIT X X TYPEWRITER ALIGNMENT GUIDE <br /> P'c" XXX .� XXX .. <br /> ,Jifornia law reoulres an amowyer to report wlthttt five days ever„Industnal injury or occupational disease which,(a)Results in lost time Devon the day of injury. <br /> ib)requires memcal treatment other tnan dist aid. PLEASE NOTE: In addstion, ,t death results or d the miury o• fitness:ta}Reouires rnaansnt ndspaanzation at <br /> ore rem 24 noun for otesr than mealcaf gbservown: or {b) results In loss of any member of the body: or fc) produces anv serious dedree'at permanent' <br /> ,is nramenr.men of nearest district eryOtfiit f71 the California Division dl OCCUC=Onal Safety and Health also must be notified lmmeaiawy oy tele none-or tefsgraptr. <br /> ,is notification Is not requtrad,ftowarsrr rt thet" <br /> or death results from an aooldent on a public street or irghway. <br /> t.SAM NAMIE- <br /> OWENS-BROCKWAY GLASS CONTAINERS IA.POLICY NUMBER <br /> Riltatt:00 N17T <br /> Usf Tess- <br /> 2.FAAIU.IQ ADDRESS 'tNum6w&w R --.Cali.apt C.f7 AWM•-- <br /> P.O. Bax 30 Tracy, Ca 95378-0030 u I' 9 NUMBER <br /> 2009) 836-8200 cAsprMo:: <br /> 3 LOCATION.IF DIFFERENT FROM MAIL AoORM: rNrrrrw-r Bares.".ZIPl <br /> 14700 W. Schulte Road Tracy, Ca 95375 3"`n`""Ol1C°0E <br /> Ooze <br /> ILA.NATURE OF BUSINESS a.p..Peris"Cis wamr rete Qwt lM►.... <br /> �r�'�"I S.STATE UNEMPLOYMENT INSURANCE ACCT.NO. _ <br /> Manufacturers of-Glass- Containers 342-6747-6 <br /> 46.TYPE OF EMPLOY"! - .. .;•` . <br /> W <br /> PMyyITE'- STATfE- CITY CQUAITY 015 OTHM(H)WRNMENYi <br /> T—SPECIFY INbnw, <br /> A <br /> a.EMPkDYEE 7.DATE OF BIRTH rMIMOavY, <br /> �t OGQ1iAT10N. <br /> s-NOME ADDRESS IN,Mnarrane S~,Coy,Zai <br /> [t{.PHONE NUMBER - - <br /> Sax" <br /> 9.SE%: MIM FFr rlr r0.dCCUPATION U4"ww pp tit*.nw sP/dAp <br /> ,I.SOCIAL SECURITY NUMBER/ <br /> 12.DEPARTMENT IN w/aCN REOLlJ1rtLY EMROYEp .. <br /> 1Ll BATE NIKE"*Ma y n - = <br /> 17.MDUIe USUALLY WORKED:IIDUA3 PER DAY <br /> 134 DAYS PER WEER iML TOTAL WEEKLY HOURS IKW*'Mtar+r COCO to vov <br /> O8 p , PONN"we wrgrs asr,WMp7 t?MV Noun <br /> 5 - 40 .E <br /> II GROSS WAGESISALARY- PER HOUR DAY WEEK TWO WEEKS KACWrH OTHER—SPECIFY � <br /> X "To PER wE�tc I <br /> 'S.WMERe OID ACCIDENT OR EVOSURE OCCURT fUMwoor res Seatt.GIy) ,SJL COUM'YN, <br /> ,$L ON EMPLOYER'S PR£MISES7 <br /> 14700 W. Schulte Rd.., Tracy Ca San JoaquinX 11111myHOUI. <br /> '6 WHAT WAS EMPLOYEE DOING wmft#" URffo M rrrrrrr,0 <br /> � IOwa•aru.Nttwa«mn.,.7Ia aTp4yer wwr�MAq.1 -. .. <br /> '� , <br /> wEtMY-WA= <br /> T HOW DID THE ACf7DE►rr On EkPOSURE OCWR7 Irtrer/,r�sllas AMI/xIa/ralltr P4,I r�Iuae w urlwY w xeromtr pnarr. rsu w11rI nroeelre ane new w nropwre. `. .. <br /> w�Irw rrawy anew a nscess"'I <br /> Cotam, <br /> 16 OtMECT-OR SUBSTANCE THAT OIREOTLT,N.lE7RELT EMPLOYEE'e. <br /> '7MWAM Mal Williams SIM sw r In CWr e1 g.. O,a m IIRCa tT9�.d nlydl RISIGI rrr:91r ra0er or cps w ~a Iwewm@d,au ::r <br /> fN esti Ielnq,ptllyp, <br /> PA*V.01F t10QY. <br /> I9A.0ESCWE THE IFUUAY OR �} <br /> IL1.HE3a e.g-�maw Kamer.fto rawk Tee. <br /> ,fB.`/ART OF BODY AFFECTED e.g..OIICa.ITR wtM.It91TI M.MCA.. <br /> 29.NAME AND ADDRESS OF PNVSKUN INuesss, n Swset-Cny.ZIP, . <br /> 445 W. Eaton Ave Tracy, Ca 95375 ACQDeJRTYPf:° <br /> 2! <br /> IF NO$pfT NAME AND AODRES.y OF If3lpRlli' {MnlrtMranp a"..-Cft.MFq <br /> oATE OFF JNjVRYOR R1NESS xl. DAYS/' _ -- - <br /> / / im -- 24.Did w+Mbyro Iese at Mitt MW kw pry's wrrr spar aM wI,Ilyr <br /> 25.HAS EMPLOYEE �;OIOi rE4-Orr uo wpm _ <br /> ► IMULOO rn 2L DID EMPLOYE♦=Der (MMLOO_YY) E CTVFrCW <br /> I+lo,pill O}l Ia0H1 Y <br /> 'date rNUrIIr�-: E'S—Ores at Deser- <br /> Mum w Mor Or wo i - <br /> 1 r�u. <br /> Patt Coyle <br /> Plant Nursp. .z <br /> I EItQO fREV.51 ' <br />