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EASE TYPE ALL YNFOIM►ATICN.IF POSSIBLE State at California MAIL ORIGINAL 6fiHk64LY TO: MAIL 2 COPIES TO: EMPLOYER'S REPORT Dept- Of Industrial Relations Gates McDonald OSHA Case T Div.of Labor Statistics 1330 Broadway. Suite 1630 or File No. OF OCCUPATIONAL San Box 603 Oakland, CA 94612 San Francisco, CA 94101 4151832.0301 1 INJURY OR ILLNESS P c"Y % X ELITEi1(X X rYPE""A ALJGNMENT GUIOE MCA XXX ELITE X X X 1liforriia law reautres an employer to report wtthM tine days every Industrial iniury or occupational disease wnJch-fat Results in lost time bevond the day of iniury, ib)requires medics{treatment other than tlrst aid.PLEASE NOTE: In adortion. it death results or d rhe intury o-Illness:tat Requires moatlent hospaattmo.n at are than 24 hours for other roan medltaf Observation- or (b) results in loss of any member of the bothr.or (c} produces any serious Demo of oermanent tlqurement.then the nearest district office of the C."tompa Division of Occupational Safety and Health also must be notified immeoiataly by teletxrone or JeWapn: is notification is not required,hpwrver'tt the tniury or death resells from an accident on a public street or nighway. I.nRMkAME - OWENS-BROCKWAY GLASS CONTAINERS I&POLICY NUMBER PLRA t00NOT use ons 2.MAILING ADDRESS IHu1aw&W SbfaR CJgr.a" CO - P-0. Box 30 Tracy, Ca 95378-0030 u209)PHONE Nu836- 8200 rAUNO. 3 LOCATION.iF DIFFERENT FROM MAIL ADORMSa e4 new alta anew,Or,.ZIM 3A.LOCATION CODE 14700 W. Schulte Road Tracy, Ca 95376 0022 AA.NATURE OF 9USpen a 9.-pa+wg banirw:Or.r,Mrri,Vow.aawn wL rr".OtaOWNWA iMP Manufacturers of Glass Containers - s.STATE""Ev°L°" "T'"�,"""`E ACCT."°' 342-6747-6 SCHOOLX 49.TYPE OF EMPLOYER:'- pTMM yA, - STATE CITY COUNTY MSTRICT OTHER GOYERNMEW—SPECIFY INptOTrrr-. c.fJAt3.0Y£E NAME - r.OATE OF 81RTH IyMM.OD.rn OCCWATTDN a.Now ADORE INontbw wo Steal.coy,an _ !!A.PHONE NUMBER v i 9.SE7L• Fonay- 10.OCCUPATCH Inopw lab Rw,rip apwe"sar w in Wo a MnsYI i i.SOCIAL sEcuntry NUMBER 12,DEPARTMENT IN wFMCH REOUTAALY EW LOYMp / �D Y '" �J Asa.: 12A.DATE OF HJRa IMM4)d.YY► 13.HOURS USUALLY WCAKIW:HOURS PER DAY Wil DAYS PER WEEK t3a,TOTAL WEEKLY HOURS }3r_Mlow VMw sass awe of vow 8:. pow w"wa9ae"&WI a'I DA"t OUM 5 40 . 1a 4118011S WAOESISALARY: PER- HOUR DAY ViM TWO WEEKS MONTH CrHER-SWECIFY X DAY!PM WMEK 'S.WHERE DID ACCIDENT OR E%POSUAS 0==INrnoW No See e.QIVI ISA.COUNTY 130.ON EMPLOYER'S PREMISES? 14700 W. Schulte Rd. , Tracy Ca.. San Joaquin YES X o trrMlBti:YMOURS e wrlAr WAS EMPLOYEE nat,90 wwEN daulRJm?IR..er aw aaac+w on WIMMI WAGE .7 HOW DID'rHE ACCIDENT OR EXPOSURE OC{M rp%"ia Ower a/iiy JIM e- Pleew ire eaOe/r e'00 A MOOftpwCM 1 agiaY er"CCialeae drabber, 1401 who eapyerieA alta now It naoaww0:- / COUNTY r NAitIR[qtr tNJtAr/ 18,OBJECT OR SUBSTANCE THAT OIREMY MUUI ED EMPLOYES•.q., ere m-rirrs eN91bI1� aglrw or wtrieil Rfla<a loll'sic - a7aaeee set wrom a Fell aabr,n COM a straw,M era MRnO. me r OIC. •spot or*MR MME"or awaaaerse:yr ..- - " � �/ �-c-�-s PAW or eopY f9A.OESCRIBE THE%AM aR JLLNESS e.9.,aii,Oban"Mme,Bet r"M OW I9a.PART OF BODY AFFECTED•.9.,OadL IBR wnM:Iain ave.etc_ I4-NAME AN"boRESS OF PMVSICLW INVm 0&4 SYNC COY.aPl 445 W. Eaton Ave Tracy, Ca 95376 AccrDafrTyvc !t aF HOSPFTAL=7%AN0 ADORE"OF HOMrAL (MAWerarM SSMC Ory.ZLM 2.DATE OF JwUAY OR ILLNEg9 /� 6 JAM-00-M `� 2].TRIS of OA a.m. 24.Did rnngYwr Iiaw ar ieae en.wr days w,"ebw'nw w"WV! A-OAL. MMdO.YY) YES-4ow Lm woo No* s.HAS EMPLOYEE RFTURNtD TO WORK? pUap,YY) 211.DID EMPLOYEE DIET [Ma+Do-vrl EX}1Ut1 of No,gill off work a owsee, .•. i w+.w a arpa w pieal iS.P. Part Go 1e i Plant N 002p