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_EASE TYPE.ALL INFORAIAT)6N.IF POSSIBLE State Of California MAIL ORIGINALQM,i i y TO: MAIL 2 COPIES TO: Dept. Of lndustriai Relations Gates McDonald OSHA Case + EMPLOYER'S REPORT Div. of Labor Statistics 1330 Broadway, Suite 1630 P.O. Box 603 Oakland, CA 94612 or Fife No. OF OCCUPATIONAL . 41518320301 San Francisco, CA 94101 _ INJURY OR ILLNESS PICA X ELITEIX X w ryPEWRITER ALIGNMENT GUIDE PICA �' % �' ELITE X WXX alifornia law requires an employer to report wlthln five days every industrial injury or Occupational disease which:fay Results in lost time beyond the day of iniury, r fb) requires medical treatment other-than first aid. PLEASE (VOTE: In addition, it death results or If the iniury o-illness: la) Requires Inoatrent hospitalization of ,Ore than 24 hours for other than medical observation: or (b) results in loss of any member of the degree of Isfigurement,then the nearest district oHfce Of the California Division Of Occupational Safety ano Health also must be n� orotified(c) produces Immea ately byany $83telephone orpermanent telegraph his notification Is not required, however,if the injury or death results from an accident on a public street or highway. 1.ARM NAME - OWENS-BROCKWAY GLASS CONTAINERS IA.POLICY NUMBER PLEASE DO NOT 2.MAILING ADDRESS {Nygpar and 8USE THIS lIeM.Gly,ZIp, COLUMN- P.O. Box 30 Tracy, Ca 95378-0030 2A PHONE NUMBER 209} 836-$200 cAss No. 3 LOCATION.IF DIFFERENT FROM MAIL ADDRESS (NU lrl w end Street,City,ZIP, 14700 W. Schulte RoadTracy, Ca 95376 7A•LOCATION CODE 0022 u-NATURE OF BUSINESS e.g.,p6µlplp valtrllor tahelarlele 00.,ahoilfes,h",ale. OWNERSHIP 342- Manufacturers of Glass Containers S.9TATEUNE►EPLINSVAANCEACCT.NO. _ 342-6747-6 aft.TYPE OF EMPLOYER: PRNATf" STATE CITY COUNTY 015 OTHER GOVERNMENT-SPECWV INDUSTRY X 8.EMPLOYEE N r.DATE OF B TH{MM_oo.YY1 `may OCCUPATION 6.HOMG AOORESS_(N �rwroft. CI 11P} z 9A PHONE NUMBER 0.SE]L � Famay� 10.00CUPATION(Reg9ear pub .hot epWAW■minty u t0y� o!1/lhlrYl �/ 7�p-j Sax - I1,SOCIAL SECURITY NUMBER t2.DEPAJfinNEtiTjlhr wFMCH REpULARLY EMPLOYED AG! /•��}/p ,f`'� /�/e;�L/- 12A.DATE OF HIRE f MWd6YY, 17.H"S USUALLY WORKED:HOURS PER DAY 1911 DAYS PER WEttl( 176.TOTAL WEEKLY HOURS t��"That clan coo*of+air 8 .5 40 pokey were wages asagaio el DAILY HOURS N.OROS$WAOESISAWRY! PEW. HOUR DAY wERx Two WEEKS Iy1QNt}{ OTHER-SPECIFY X DAYS PER WEEK 'S-WHERE Oto ACCIDENT OR EXPOSURE OCCUR?fNumeer ane street,City! 1y1 COUNTY 14700 W. Schulte Rd. , Trac Ca 156.ON EMPLOYER'S FREMtSE57 ? Y San Joaquin YES X .O WEEKLY HOURS 6 WHAT WAS EMPLOYEE DOING WHEN MJURED7(Pkat'to weemp.kion"NNXS.emm"Imle of maeelw tr»,em OIDYw waauarn4.1 WEEKLY WAGE T HOW DID THE ACCIDENT OR EXPOS.l URE OCCUR?fPkaae o1 icnitm IWIy the Mnts!net reaaeed Ih-IL"Of OpyDWgnr daeew. roi enM nopNrO SM how h hauver m. Pkre uaa aawrare 0reat a naeeaeay COUNTY - NATURE OF INJURY 14l.OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE e.g., Ole ma6lw N, akyck ChMucal the 011#900 no skin:n 01 atrarlrl, 1twltq M Tiding,pulling,Ole. agent Or whch shtick hlnr, the V=W or Domt•tl9hayd or Swelkwed: the _ �' ��.��- =�'• PART OF BODY 19K DESCRI13E THE INJURY OR ILLNESS e.g..aa.ahei.to emirs,akr,reap,alt. 19B.PART OF BODY AFFECTED e q..Deck w11 wrM.Rgh1 eye,arc. h SOURCE 20 NAME AND ADDRESS OF PHYSICIAN (Nut*a and Strain.CSV ZIp) 445 W. Eaton Ave Tracy, Ca 95376 ACCUDOff TYPE 21.IF HO IZED.NAME AND ADDRESS Of HOSPITAL (Numporand Sirdar,Cry.LPI 22,DATE OF INJURY OR ILLN - •— ;MMoo,YY1 $TAJE DAYS a.�. 24.Old elnowyee low M haat one hie key's work after die mryryl A.0.S. 25.Fh14 EMPLOYEE RETURNED TO WORK? �NORES—Due Lan Worked: lr"gr-MYY) 26.DID EMP_WYEE DIET iMh40¢YY) EXTEIfT OF INJURY No,!till off work Vim, Id nfvrlaC: �) YES-Gey of DOW -- COD=SY-^ aeau a Y taus a Dhh11 Srglreke- Title Day Patt Co Ie P1 ant N A IMOt26(REv.SI ,a.�'