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EASE TYPE ALL INFORMATION:IF POSSIBLE' ' <br /> State of California MAIL ORIGINAL liiAl CTLY TO: MAIL. Z COPIES TO: <br /> Dept. Of Industrial Relations Gates McDonald r <br /> EMPLOYER'S REPORT, OSHA Case <br /> Div. of Labor Statistics 1330 Broadwav, Suite 1630 or File No. <br /> OF OCCUPATIONAL P.O. Box 603 Oakland. CA 94612 <br /> San Francisco, CA 94101 4151832.0301 <br /> INJURY OR ILLNESS Y <br /> 'n;.X % % ELITE % ' TYPEWRI'TER ALIGNMENT GUJOE <br /> il}ornla law requires an employer to r 'rcA X X ( Et nE ><X X <br /> eportwtthln five days every mdustnal injury or occupational disease which:tai Results in lost time DevOtid the day at injury. <br /> It))requires medical "89111Tlem Other than tint aid. PLEASE NOTE- in addition. if death results or it the thtury o,hllness:gal Requires Inoatlem hospttauzatlan or <br /> to than 24 hours for other than medical observation: or tb) results In loss of any member of the body: or (c) produces anv serious oegns of permanent <br /> hqurement,"nen the nearest district office at the California Division of Occupational Safety and Neeith also must be notified Imtneaiatel tet s noldicauon is not required.hOwavwi A the injury or death results from an accident on a public street or highway. y�' riDtlDne or tttfttgrapp: <br /> I FIRM NAME - <br /> OWENS-BROCKWAY GLASS CONTAINERS IAA.POLICY NUMBER PUL4wobNor <br /> �Tum, <br /> _.MAILMKt ADORE$tt fNme•r sm etr•Hi..pry.Ztpf COUJJIIN <br /> 83 - <br /> P.O. Bax 30 Tracy, Ca 95378-0030 71LPFK1NaNUMBER <br /> 209) 836-8200 cA,nito. <br /> ] LOCATION.W DIFFERENT FROM MAIL ACORESS IFIL~Wo StI••r.C1ry,ZIP) <br /> 0 <br /> 14700 W. Schulte Road Tracy; Ca 95376 '~`G` 022 DE <br /> 0022. <br /> 4A NATURE OF SUSINESB•.g.,D&V"VWWS=,.afwfafr•dims.fawtwf.IlorM.M0. <br /> Manufacturers Of Glass Containers - ' " u" PL342-6747-� <br /> MSUMNCE ACCT.NO. <br /> 4e.TYPE OF EMPLOYER. - <br /> 342 <br /> PR1YAW STAT; CITY COUNTY <br /> XDIS OTHER 0OVERNMENT-SPECULY lkOtIBTAr' <br /> . <br /> 6 EMPLOYE NAME- ` _ <br /> 7.OATS OF elRTBIRTHIMM-00.YY1/d/�Y�S f OCOVATION <br /> 0.MOMS ADDRESS fNlfeler•n• Zpt ,�-�- &l PHONE NUMBER <br /> Srtt;: <br /> Ffnyl•. t0: AST,-1�o�N IR4gtrr Ia•LIy,not a0fetla aetr.Nv r a»r n4tM71 11.SOCIAL SECURITY NUMBER <br /> 12.DEPARTMENT wNlClf AEOULJ1RLT E�r�/ <br /> 6- <br /> 12A,DATE OF NIRS IMM-00 <br /> tamed <br /> 13.H011f19 USUALLY WORKED:HOURS PER PAY 13t DAYS PER WEEK t 17C. tirnM m Lasa p roar <br /> ]a..TbTAL WEEKLY HOURS <br /> 5 40 POW VA"-+gw&LINW1r•t DALLY"OURS <br /> - - <br /> 14 GROSS wAOESPSALMY: PEW HOUR DAY WEEK TWO WEEKS MONTH OTHER.-SPECIFY <br /> X DA"1PER Va" <br /> 'S.W WM 010 ACCIDENT OR EXPOSUpe OCCLWa R*Mvmw rt•atr••e.oty1 isA.COUNTY Ise.ON EMPLOYER'S PREMISES? <br /> 14700 W. Schulte. Rd. , Tracy Ca San Joaquin X wtl6aY"OURS <br /> 6 WHAT WAS EMPLOYEE DOING WHEN YES '+O <br /> ••Mlar4af.mpNfY Io•Is,•etnrtwwer e+nrlr � <br /> WEMY WAGE <br /> 7 I+OW d0 TME ACCDENr OR EXPOSURE O[.CU"IPI•r•rfrf•kov Ih•a+rNrarr�fnlaf•� <br /> pHa••wr a�o4ralf rwnt f n.p�r". f+NMY r aQigatpn•I dlMar.^r«1.hr ftMM"•anf hI-N napeplfo, <br /> COUNTY <br /> .. MANOW OP Irt.ium <br /> I-OBJECT OR SUBSTANCE THAT 171Rti my ftxwEb EMROYEE e.g.. the mann. <br /> Otmum nr rntow rm swc n tel a of fCaR M " +rr r/p/m �N 7 feu/e/t�q�HX wrCr1 Mari hnr-M www or 9c .smog"r fraa•w•• otf <br /> r i PaYrq.4Ka 7 L: <br /> PART OF e00Yr <br /> 1A.OE9L711 TIRE lkAlRr OR 111.0E$$•.q..HAf,Mrs ltamra fan Bee I9b-PART OF BODY AFFECTEp.. — <br /> $O{wCE <br /> 0.NAYS AND ADOREE9 OF PHYSK;UW IN,00WIln•gna.pay.ZIP) <br /> 445 'W. Eaton Ave Tracy, Ca 95376 AOX:MVMTTif" � <br /> I rt How" <br /> NAME AND AaI0AES$OFAUMD <br /> C GATE OF INJURY rl1N�/t <br /> 23_ Gf�^- ✓//� <br /> .41ALa0.YV1�' "AOF DAY 4� a.m. �]' 4.OI4 Mwplorr ter r Iwt on.Aetl sips wont flfr Hn.tnryrl/j <br /> S.NAB EMPLOYER RETURNED �- ' YE-0-4)ND lap warms <br /> /�^! �'rn 2a.010 EMPLOYEE DrEET fMM4WYY1 IXTVi rOP <br /> NO,still.eK Wentdate IBIIBioa�' <br /> C4 /NOi) vES-D.r d o.rte <br /> conarw <br /> me M IIyOa w pniq <br /> 0" Dao. <br /> Patt Co le i Pant Nurse <br />