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,EASE TYPE ALL wFOAMAT".IF POSSIBLE —�.��. L✓y (fes State of Cafltgrniia MAIL ORIGINAL Oi—RI&LY TO: MAIL 2 COPIES TO: Dept. Of Industrial Relations Gates McOonafd OSHA Case F EMPLOYER'S REPORT Div. of tabor Statistics 1330 Broadway, Suite 1630 OF OCCUPATIONAL P.O. Box 603 Oakland. CA 94612 or File No. San Francisco, CA 94101 4151832-0301 INJURY OR ILLNESS P,C!MLX tYpgyrRFTER ALIGNMENT GUIDE ELITE ICA alitomle law reoulres an employer 10 report within thm days every industrial iniury or occupational disease which-(a)Results in lost'time�beyond the day%ot iniury, rbj reouires medical treatment other loan hist aid.PLEASE NOTE: In addition, it death results or It tine iniury o-Illness: lal Redulres moatlenr hospitalization of are tnan 24 hours tar other titan mealeal obaarvatton: or ib► results In loss at any member of the shgurement.then tree nearest district office of the California Division of Occupational Safety and Health at o Mustt 00 notified Immediatelces anv y telephone orcearee at iel anent tis notification Is not required.however.d the mtury Of death resuits from art acctdent on a public street or highway. y y aph. p.FIRM NAAta OWENS-BROCKWAY GLASS CONTAINERS IA.POLICY NUMBER PLUM pp NOT USE twfs 2.MAILMYG AOCAM (Naeeer two ow Co.LPI COLUM. P.O. BOX 30 Tracy, Ca 95378-0030 2A.PHONE NUMBER 83 209} 835-8200 c.ASEMo. 3 LOCATION.IF DIFFERENT FROM MAIL ADDRESS ft/wow Ana e"U".City.IIP) 14700 W. Schulte. Road Tracy, Ca 95376 tOGpTlONcoDE 0022 aA.NATURE of BUSINESS e.p.,parewq em.atsr.wtoeinoa oda ee eaww".tmM,etc. Manufacturers Of Glass Containers- - I- 342-6747-6 ""E"r'"�'�""�EA�cT.N°. aa.TYPE OF EMPLOYER: - 3 PW4'AW' STAT; CITY cowry OIS OrH"l QCVERNMGNT—SPECIFY fNOY�TgT.. X 6 EMPLOYEE 7.DATE gP BIRTH fMMD.Y // OCCUPATION� Vp E.HOURS AODRESS INto we SM ensa..CUY.LPI &JL PHONE NUMBER 9.5EII: to.OCCUPATION alle"w.pe mla.not Wetlae 40M?W M mne a MKOP pe.SOCIAL SECURITY NUMBER e2.DEPARTMENTtN WHICH REGULARLY EMFl01rEO AOI}.... 12JL DATE OF HIRE t A-mm 13.HOURa USUALLY WORKED:HOURS PEA DAY 13k LA / / a rev YS PER WEEK pie.TOTAL WEEKLY HOURS 13(F 8 C 40 Palal••r.r«,«nuWlwl CAL E.NdURS II OAOSS WAGESI'.,ALARY7 O pew HOUR JOAY WEEK TWO WEEKS V MONTH OTHER SPECIFY $ .. X ars PM WEEK 'S.WNW 010 ACCIDENT OR EXPOSURE OCCURT(N wmwr ane Street.Cay1 pyo COUNTY 14700 W. Schulte Rd. , Trac Cd ISB.ONEMp4OYER'5pREMtSE57 Y San Joaquin ' X WEMMY HOURS I WHAT WAS EMPLOYEE DOING WHEN oatuftwT IPIe�a eeaama.jova ,.� YES o. Twwwr wpe nnwlaraewweuw10.1 WEEKLY WAGE +7 IiQW Oto THE A4r ENT OR EXPOSURE OC•t3nt7 pPrser►aeeelltw AlaY Pepe"W"09At phi Ire eewaer rtiw a r4c4 euv.t Irerw rr mKrr or wpma aerew.,fee rww h4ow"d mm now w nenwlwa. COUNTY -- NAZUAFOF IIrJUntl ,e OR SUBSTANCE AT btRECTLY L EMPLOYEE hem�rwlma"r eratB�eLea nieM -swim agewNt or wftm rnx%N"r as VEAW w oamt mwd 7- � '' 4,at& or,.rawoww:>ti . PMT OF eODT :9A.DESCRIBE THE INJURY OR MLNM e.p„on.wUM6 trgaVft SM feeeii.W IV&PART OF BODY AFFECTED e.q..ilex,teR whet.nghe wre.MG ' 29.NAME AND ADDRESS OF P"VSK AN +Nyn,eet an SWOW.Coy.apt 445 W. Eaton Ave Tracy, Ca 95375 6, �5-0 ACCWZNT TYPE II IF HOSPITAL NAME ANO ADDRESS OF HO9PITAL INw~@M Stow,-QtY.21P1 i2.DATE OF IwURY OR ILLNE oa+m e,J� uu23 TIME OF DAY A ap, 2a, Slow" N Frlh A.O.E.. uM-06vn u.HAS EMPLOYEE RETURNEDTO WORKT YES-011"Lm WOO ft* {M14pGW1 20.DID EMPLOYEE DIE? (I M.MYY) EXIVIT OF - No.Still off worm'- Jr6e•�aia t7rl/ir¢'.. YES-44ft at Dowr CoOm'2V - I�aa w"M or erswr r'pH DAM Path CoyleI Plant N Step rREy.Si _.